Monument Healthcare Brigham City

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible, and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 2 out of 20 sampled residents, the facility failed to implement new or revised interventions after consecutive falls. In addition, the locked unit was left without nursing staff supervision for multiple periods of time and a resident wandered into other resident's rooms. Resident identifiers: 13 and 21.

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, hand hygiene was not done according to professional standards and there were soiled areas in the kitchen.

Inspectors wroteBased on observation and interviews, for 4 of 20 sampled residents, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, a resident had a clothing protector placed on her by another resident as she said she was headed to the bathroom. The resident was observed to enter her bathroom and return to eat with the same clothing protector. Another resident's oxygen tubing was on the floor in the dining room and staff placed the tubing on her face and nasal cannula in her nose. In addition, the Hoyer lift was not sanitized between residents' use. Resident identifiers: 4, 6, 26, and 29.

Inspectors wroteBased on interview and record review, the facility must ensure that a resident's physician was immediately consulted when there was a significant change in the resident's physical, mental, or psychosocial status. Specifically, a nurse failed to immediately consult with the resident's physician following a significant change in a resident's psychosocial and behavioral status involving homicidal threats and the subsequent withholding of ordered pain medication. Resident identifier: 33.

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. Specifically, for 1 out of 20 sampled residents, a resident taking an antidepressant medication for insomnia did not have hours of sleep monitored. Resident identifier: 21.

Inspectors wroteBased on observation, interview, and record review, for 1 of 20 sampled residents, the facility did not ensure that pain management services were provided in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals. Specifically, a nurse failed to timely assess and administer a prescribed as-needed (PRN) opioid pain medication to a resident experiencing pain after repeated requests from the resident and alerts from multiple certified nursing assistants (CNAs). The resident experienced pain, which was described by the resident as agony, for more than four hours. Resident identifier: 33.

Inspectors wroteBased on interview and record review, it was determined that for 1 out of 13 sampled residents, the facility did not ensure residents had a right to be free from neglect. Specifically, a resident was left in a wet brief for an extended period of time and sustained a rash and excoriation to the groin. This resulted in a finding of harm for the resident. Resident identifier: 9.

Inspectors wroteBased on interview and record review, the facility did not ensure that the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, for 1 out of 27 sampled residents, staff were unable to locate a resident for a period of time. There was an area of the facility that was locked an unaccessable to staff. There was a facility staff member in the locked area that the resident was observed to exit from. The resident made statements that the staff member engaged in sexual actions with her. In addition, the staff member had been talked to about not remaining in the facility after dinner time. This example was cited at Immediate Jeopardy. Resident identifiers: 4, 6, 12, 23, 28, 31, 36, 90 and 141.

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dish machine washing temperature was not manufacture required temperature and there were no sanitizer strips available to test the solution.

Inspectors wroteBased on observation and interview, the facility did not provide a clean, comfortable, homelike environment. Specifically, there were odors throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, for 4 out of 27 sampled resident, residents complained of food quality and a test tray was bland. Resident identifiers: 4, 9, 15, and 27.

Inspectors wroteBased on observation and interview, the facility failed to provide a suitable, nourishing alternate meals and snacks for residents wanting to eat at non-traditional times, or outside of scheduled meal service times. Specifically, for 5 out of 27 sampled residents, residents were only offered saltine crackers for snacks. Resident identifiers: 3, 4, 6, 31, and 141.

Inspectors wroteBased on interview and record review, the facility did not develop and implement written polices and procedures that prohibited and prevented abuse, neglect, and exploitation of residents. Specifically, a staff member was not connected to the facility through the Direct Access Clearance System (DACS).

Inspectors wroteBased on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs. Specifically, for 1 out of 27 sampled residents, a resident did not have an intervention implemented from his care plan which resulted in multiple falls, a skin tear, and hip pain. Resident Identifier: 9.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the resident environment remains free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 27 sampled residents, a resident did not have an assistance device to prevent falls which resulted in multiple falls. Resident Identifier: 9.

Inspectors wroteBased on interview and record review, it was determined, the facility did not conduct comprehensive assessments of residents in accordance with the timeframe's specified. Specifically, for 3 out of 31 sampled residents, comprehensive assessments of residents were not completed at least once every 12 months. Resident identifiers: 13, 90, and 91.

Inspectors wroteBased on interview and record review, it was determined, the facility did not assess residents using the quarterly review instrument specified by the State and approved by Centers for Medicare & Medicaid Services not less frequently than once every 3 months. Specifically, for 13 out of 31 sampled residents, quarterly Minimum Data Set (MDS) assessments were not completed every 3 months. In addition, quarterly MDS assessments were not completed no later than 14 days after the assessment reference date (ARD). Resident identifiers: 1, 2, 3, 4, 6, 9, 13, 16, 26, 30, 89, 90, and 142.

Inspectors wroteBased on interview and record, it was determined, the facility did not encode discharge Minimum Data Set (MDS) assessment data within 7 days after a facility completes a resident's assessment. Specifically, for 3 out of 31 sampled residents, discharge assessments were not completed and transmitted. Resident identifiers: 5, 11, and 14.

Inspectors wroteBased on interview and record review, it was determined, the facility did not comprehensively assess a resident within 14 days after determining, or should have determined, that there has been a significant change in the resident's physical or mental condition. Specifically, for 1 out of 31 sampled residents, a resident that was discharged from Hospice services did not have a significant change Minimum Data Set (MDS) assessment completed. Resident identifier: 2.

Inspectors wroteBased on interview and record review, it was determined, the facility assessments did not accurately reflect the resident's status. Specifically, for 1 out of 31 sampled residents, a resident's discharge Minimum Data Set (MDS) assessment was coded incorrectly by indicating that a resident was discharged to a hospital when the resident was actually discharged home. Resident Identifier: 40. Findings Included: Resident 40 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, difficulty in walking, muscle weakness, and arthritis. On 6/23/22, resident 40's medical record was reviewed, and it was revealed that the discharge MDS assessment indicated that resident 40 had been discharged to an acute hospital. A progress note dated 4/16/22 at 9:13 AM, was reviewed. The progress note documented, Discharge Summary: [...]

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 31 sampled residents, a resident's medications to treat high blood pressure were held without physician ordered parameters. Resident identifier: 30.