Monarch Springs Wellness & Rehabilitation

Inspectors wroteBased on observation, interview and record review, the facility failed to store and serve food in accordance with professional standards for food service safety. The facility failed to maintain kitchen equipment in a clean condition and failed to ensure that the floors were swept and mopped during three of four days of observation. The facility also failed to ensure that the wash and rinse cycles reached the required temperatures during the dishwashing process on the dishwasher. The census was 53.1. Observations of the kitchen on 5/4/26 at 6:53 A.M., 5/5/26 at 4:45 P.M, and 5/6/26 at 11:36 A.M., showed:-Stove: -Caked-on stains along the front and on the top of the stove; -Caked-on stains and spots on the burners on the stove; along the front;-Oven: -Right side: -Heavy caked-on stains along the front inside doors; -Heavy caked-on stains along the bottom, top, and sides of oven; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide or offer vaccinations for influenza and/or pneumococcal disease for four of five residents sampled for immunization status. The sample was 16. The census was 58. Review of the facility's Pneumococcal Disease Prevention policy, revised 6/2020, showed:-Before offering pneumococcal vaccines, each resident or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization;-The resident or the residence legal representative has the opportunity to refuse immunization, with such refusal being noted in the residence medical record;-The resident's medical record includes documentation that indicates, at a minimum, the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided one (Resident #51) of 16 sampled residents with the appropriate bed rails to assist with repositioning. The census was 53. Review of the facility's Bed Rails policy, revised June 2020, showed:-The assessment of whether to use bed rails should include an evaluation of the alternatives to the use of bed rail that were attempted and how these alternatives failed to meet the resident's needs;-If bed rails are to be used, the assessment Bed Rail Utilization by a licensed nurse and or the IDT (Interdisciplinary team);-The licensed nurse and/or the IDT-restraint reduction committee may refer to the bed rail decision tree during the assessment;-Before installing a bed rail, the facility must: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow appropriate discharge procedures for one resident when staff failed to re-admit the resident after returning from the hospital following an immediate discharge (Resident #50). The sample size was 16. The census was 53. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain and/or follow physician orders for three residents (Residents #37, #9, and #41). The facility failed to ensure blood pressure parameters were followed prior to medication administration (Resident #37). The facility failed to administer meal supplements (Resident #9) and failed to update dietary orders (Resident #41). The sample size was 16. The census was 53. Review of the facility's Physician Orders policy, revised June 2020, showed:-Policy: The medical records department will verify that physician orders are complete, accurate, and clarified as necessary;-Procedure: Telephone orders: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff completed bed rail assessments and updated care plans, for two residents (Residents #43 and #33) whose beds were equipped with assist rails. The sample was 16. The census was 53. Review of the facility's bed rail policy reviewed June 2020, showed:-Purpose: -To determine the appropriateness of bed rail use for individual residents;-Policy: -Decisions to use or to discontinue the use of a bed rail will be made in the context of an individualized resident assessment using an Interdisciplinary Team (IDT) and will take into account the resident's medical needs, comfort, and freedom of movement.-Procedure: -The Assessment of whether to use bed rails should include an evaluation of the alternatives to the use of bed rail that were attempted and how these alternatives failed to meet the resident's assessed needs; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the physician provided responses to pharmacist recommendations for three sampled residents (Residents #43, #33, and #4). The sample was 16. The census was 53. Review of the facility's Medication Regimen Review policy, effective August 2020, showed:-Purpose: -The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received medications as ordered by the physician. Concerns were noted when one resident's (Resident #18) blood pressure was not taken prior to the administration of an anti-hypertensive (blood pressure) medication and when one resident's (Resident #10) medication was dropped on the floor and unable to be replaced from the medication cart. The medication error rate was 5.41%, with concerns noted with two of 37 observed medications administered. The sample size was 16. The census was 58. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medications and biologicals in facility medication rooms. Concerns were noted when 17 bags of intravenous antibiotics were noted in one of two facility medication rooms. The sample size was 16. The census was 53. Review of the facility's Storage of Medications policy, revised 9/2018, showed:-Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) are permitted to access medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow acceptable standards of practice for infection control when staff failed to use Enhanced Barrier Precautions (EBP, precautions for use during high-contact resident care activities to reduce transmission of multidrug-resistant organisms (MDROs, microorganisms that are resistant to one or more classes of antimicrobial agents) as recommended by the Centers for Disease Control and Prevention (CDC) and as required by the Centers for Medicare and Medicaid Services (CMS) when staff failed to wear a gown and glove while providing direct care to one resident (Resident #9) and by failing to ensure appropriate personal protective equipment (PPE) was easily accessible by the room of one resident (Resident #33) with physician orders for EBP. The sample was 16. The census was 58. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide accessible information on the location of the State Long-Term Care Ombudsman program or the State Survey Agency hotline number that was readily available to residents in the facility without assistance. The census was 53. Observation on 5/4/26, 5/5/26, 5/6/26, and 5/7/26, showed no posted information for the State Long-Term Care Ombudsman program or the State Survey Agency hotline number in the facility entrances, dining room, and halls of each unit. During a group interview on 5/6/26 at 11:30 A.M., nine out of nine residents said they did not know where the information regarding the State Long-Term Care Ombudsman program and/or the State Survey Agency hotline number was located. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident with a history of elopement was provided with adequate supervision and staff oversight (Resident #2). On 3/10/26 at approximately 11:20 A.M., staff observed through the window that the resident was outside, across the street from the facility. The resident had a wanderguard (device that sets off an alarm when the person wearing it attempts to exit the facility) on his/her wheelchair and was able exit the building unnoticed through one of two exit doors on the second floor, which were alarmed but did not have a wanderguard sensor. The facility identified 10 residents who were at risk for elopement. The sample was 4. The census was 58. Review of the facility's Wandering and Elopement Policy, dated 08/2020, showed the following:-Purpose: To enhance the safety of residents of the facility;-Policy: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one resident's legal guardian of a change of condition and transfer to a hospital (Resident #3). The sample size was 4. The census was 45. Review of the facility's Change of Condition Policy, dated 1/2025, showed the following:-Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner;-Policy:- Definition: An acute change of condition (ACOC) is a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death;-I. Members of the Interdisciplinary Team (IDT) are expected to report and document signs and symptoms that might represent an ACOC;-II. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care and services to ensure one resident (Resident #1) was free from accident hazards when a Certified Nurse Aide (CNA) failed to secure the resident in bed before leaving to answer the call of another resident in a different room. The resident rolled of the bed and hit his/her head on the floor. The resident suffered two lacerations to the top of his/her head. The sample was four. The census was 44. The Administrator was notified on 1/31/25 at 2:53 P.M., of the past non-compliance, which occurred on 1/16/25. The facility provided training and in-servicing for all staff regarding the facility's resident safety policy. The facility also updated the resident's care plan to ensure the resident's bed is in the lowest position with a mat next to the resident's bed. The deficiency was corrected on 1/20/25. [...]

Inspectors wroteBased on observations, interviews, document review, and facility policy review, the facility failed to ensure cleanliness and ensure food stored in one of one kitchen and in the unit nourishment room, was labeled, dated, and not expired. The failure had the potential to increase the prevalence and spread of foodborne illness and infection for 49 census residents.

Inspectors wroteBased on interviews, and document review, the facility failed to ensure that a facility with more than 120 beds employed a full time qualified social worker which included a bachelor's degree in social work or a bachelor's degree in a human services field and one year of supervised social work experience. This failure has the potential to cause residents to not receive the necessary services to maintain as normal a possible lifestyle.

Inspectors wroteBased on interviews and facility policy review, the facility failed to ensure infection control measures were appropriately implemented and maintained for Legionellosis assessment and prevention in the facility. This failure has the potential to affect 49 of 49 census residents. Finding Include: Review of website for ASHRAE [he American Society of Heating, Refrigerating and Air-Conditioning Engineers] titled Risk Management for Legionellosis, dated 10/15, located https://www.ashrae.org/, indicated .The design engineer first needs to evaluate which requirements of the standard apply to their project. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to promote a dignified dining experience by serving beverages in disposable cups, and food on disposable plates at meals for one Resident (R) 24 and one of two dining rooms of 23 sample residents. This failure had the potential to affect all residents who were served meals prepared in the facility's one of one kitchen.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to maintain a clean and comfortable environment for two of the two dining rooms. This failure had the potential to affect all residents who ate meals in the facility's two dining rooms.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure expired medications and supplies were removed from one of one treatment carts, one of one medication rooms and failed to ensure one of one treatment cart and one of two nurse carts were locked. This had the potential to affect any resident who might be administered expired medications/use of expired supplies. The unlocked carts had the potential to be accessed by unauthorized residents, staff, and visitors.

Inspectors wroteBased on observations, interview, and facility policy review, the facility failed to ensure the facility's dumpster container lids were kept closed when not in use for 49 census residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for one of three residents (Resident (R) 3) reviewed for Preadmission Screening and Resident Review (PASARR) of 23 sample residents. This failure placed the residents at risk of having unmet care needs and services.

Inspectors wroteBased on observations, record review, interview, and facility policy review, the facility failed to provide services based on acceptable standards of practice by specifically failing to accurately check a finger stick glucose level and failing to keep a clean field clean during wound care for two of two residents (Resident (R) 3 and R8) reviewed for professional standards of 23 sample residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to serve food that was palatable for three of four (Residents (R) 3, R12, and R24) reviewed for food palatability of 23 sample residents. This had the potential to affect 49 of 49 residents who consumed food that was prepared from the facility's kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the daily posted nurse staffing information contained complete information which included the total number and actual hours worked of licensed and unlicensed staff on duty. This failure had the potential to affect all residents and visitors to the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide a resident with an appropriate involuntary transfer discharge when they transferred one sampled resident (Resident #1) to the hospital and would not allow him/her to return, out of three sampled residents. The facility census was 51 residents. Review of the facility's admission Criteria policy, revised 03/2019, showed: -Our facility admits only residents whose medical and nursing needs can be met; Policy Interpretation and Implementation: -The objectives of our admission criteria policy are to: -Admit residents who can be cared for adequately by the facility; -Assure the facility receives appropriate medical records prior to or upon the resident's admission; -Prior to or at the time of admission, the resident or representative is informed of any service limitations or special characteristics of the facility; [...]

Inspectors wroteBased on interview and record review, the facility failed to revise and/or update one resident's care plan after each event of verbal and/or physical aggression, failed to update/revise interventions, and failed to train facility staff how to properly implement the residents current care planned interventions (Resident #1). The sample was 3. The census was 51. Review of the facility's Comprehensive Care Plan policy, revised 09/2010, showed: -Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident; -Enhance the optimal functioning of the resident by focusing on a rehabilitative program; -Reflect currently recognized standard of practice for problem area and conditions; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident behavior triggers, which may have predisposed the resident's aggression, were adequately monitored and addressed. Staff did not develop interventions to address the resident's behavior to deter him/her from responding aggressively towards other residents and staff (Resident #1). The sample was 3. The census was 51. Review of the facility's Comprehensive Care Plan policy, revised 09/2010, showed: -Policy Statement: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident; -Enhance the optimal functioning of the resident by focusing on a rehabilitative program; -Reflect currently recognized standard of practice for problem area and conditions; [...]

Inspectors wroteBased on observations, facility policy review, and interviews, it was determined that the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in the kitchen and during one of one meal service observed. Specifically, observations revealed the facility failed to : 1. Remove dented cans from the dry storage area; 2. Maintain food and refrigerator temperature logs; 3. Sanitize the thermometer between food items during observations of meal service ; and 4. Perform appropriate hand hygiene while plating food during meal service. This deficient practice had the potential to affect 33 of 36 residents of the facility that received food from the kitchen.

Inspectors wroteBased on observation, interview, record review, document review, and facility policy review, it was determined the facility failed to provide pharmaceutical services to establish and maintain a system to ensure drug records were in order and that accounted for all controlled drugs. Specifically, the facility failed to ensure narcotic medications were reconciled and loss or potential diversion was identified for 3 (Residents #19, #22, and #180) of 18 residents reviewed who were receiving narcotic medications.

Inspectors wroteBased on observations, interviews, and facility policy review, it was determined the facility failed to ensure controlled substances were stored in separately locked, permanently affixed compartments in 1 medication room; failed to ensure medications and biologicals were labeled in accordance with accepted professional principles on 2 of 2 medication carts; failed to ensure expired medications were not available on 1 of 2 medication carts; and failed to ensure an emergency drug kit was locked.

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified social worker on a full time basis. The census was 34. Review of the State Operation Manual (SOM), showed a qualified social worker, for a facility with more than 120 beds defined as: An individual with a minimum of a bachelor's degree in social work or a bachelor's degree in a human service field including but not limited to sociology, gerontology, special education, rehabilitation counseling and psychology and one years supervised social work experience in a health care setting working directly with individuals. Review of the facility's license and certification records, showed the facility was licensed for 130 beds, of which 130 beds were certified for Medicaid and Medicare. Review of facility's current employee roster, showed the Social Service Designee (SSD) date of hire was 2/2/22. [...]

Inspectors wroteBased on observations, interviews, record reviews, and review of facility documents, policies and Centers for Disease Control and Prevention (CDC) guidelines, it was determined that the facility failed to consistently implement infection control measures. Specifically, the facility: 1. failed to ensure staff were wearing appropriate personal protective equipment (PPE), per facility policy, when entering the room of 1 (Resident #13) COVID-19 positive resident of 5 sampled residents. 2. failed to ensure staff were wearing appropriate PPE, while handling soiled laundry in 1 of 1 laundry area to prevent potential cross-contamination of the staff member's clothing which could result in subsequent contamination of clean laundry. The facility census was 36.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure medication self-administration was assessed for 1 (Resident #279) of 16 sampled residents. Observations revealed medications were left at Resident #279's bedside; however, the facility failed to assess the resident to ensure self-administration was clinically appropriate. The facility census was 36.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility failed to ensure the resident's right to receive services in the facility with reasonable accommodation of needs was met for 1 (Resident #3) of 3 residents reviewed for accommodation of needs. Observations and interviews revealed Resident #3 had a wheelchair that did not meet their positioning needs.

Inspectors wroteBased on interviews, record reviews, and policy review, it was determined the facility failed to ensure resident Minimum Data Set (MDS) assessments were completed and submitted timely for 3 (Residents #13, #8, and #22) of 3 residents reviewed for timely assessment transmission.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, it was determined the facility failed to maintain all patient care equipment in safe operating condition for 1 of 4 mechanical lifts used in the facility to transfer residents. Observations revealed a mechanical lift was not properly working and staff failed to report the issue to maintenance staff. This deficient practice had the potential to affect nine residents in the facility who utilized mechanical lifts for transfers.

Inspectors wroteBased on facility document review, interviews, and review of facility policy, it was determined the facility failed to ensure 1 (Dietary Aide #17) of 46 staff were fully vaccinated against COVID-19 or had a qualifying exemption or reason for temporary delay.