Monument Healthcare Canyon Rim

Inspectors wroteBased on interview and record review, it was determined for 2 out of 10 sampled residents that in response to allegations of abuse, the facility failed to report allegations immediately. Specifically, allegations of abuse were not reported to the State Survey Agency (SSA), Adult Protective Services (APS), or the police. This was determined to have occurred at an Immediate Jeopardy level for resident 5. Resident identifiers: 1 and 5. On 12/12/2024, a finding of Immediate Jeopardy (IJ) (immediate threat to the health and safety of patients) was identified in the area of 483.12 Freedom from Abuse, Neglect, and Exploitation. The facility was notified of this finding verbally and in writing on 12/12/2024 at 10:20 AM. The facility submitted an IJ removal plan on 12/12/2024 at 3:41 PM, alleging removal as of 12/12/2024 at 2:30 PM. [...]

Inspectors wroteBased on interview and record review, it was determined that in response to allegations of abuse, the facility failed to have evidence that all alleged violations were thoroughly investigated for 2 of 10 sampled residents and prevent further potential abuse while an investigation was being processed for 1 of 10 sampled residents. Specifically, the facility did not have evidence that abuse allegations were thoroughly investigated and allowed an alleged perpetrator to continue to have access to the alleged victim and other vulnerable residents. This was determined to have occurred at an Immediate Jeopardy level for resident 5. Resident identifiers: 1 and 5. On 12/12/2024, a finding of Immediate Jeopardy (IJ) (immediate threat to the health and safety of patients) was identified in the area of 483.12 Freedom from Abuse, Neglect, and Exploitation. [...]

Inspectors wroteBased on observation and interview it was determined the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality. Specifically, for 4 out of 28 sampled residents, staff referred to resident's who required dining assistance as feeders, a resident was told the location of where he needed to eat his meals, residents were observed to wait for their meal trays while their tablemate's ate, and a resident waited approximately 46 minutes for his lunch tray to be served. Resident identifiers: 12, 17, 37, and 49.

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 4 out of 28 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, 4, 7, and 32.

Inspectors wroteBased on interview, it was determined, the facility did not ensure that individual financial records were available to the residents through quarterly statements and upon request. Specifically, for 1 out of 28 sampled residents, a resident did not receive quarterly statements regarding his personal funds. Resident identifier: 12.

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 2 out of 28 sampled residents, a residents comprehensive assessment was not completed at least once every 12 months. In addition, a residents admission Minimum Data Set (MDS) assessment was not completed within 14 days after admission. Resident identifiers: 40 and 105.

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 28 sampled residents, a resident's Minimum Data Set (MDS) annual assessment was coded incorrectly by indicating the resident was not on hospice when the resident was on hospice. Resident identifier: 40.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that the pharmacist's reported irregularities of a resident's drug regimen were reported to the Medical Director (MD) and the reports were acted upon. Specifically, for 1 out of 28 sampled residents, the facility did not implement the MD orders as they pertained to the pharmacist's recommendations. Resident identifier: 12.

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 2 out of 28 sampled residents, a resident's beta blocker medication to treat tremors, anxiety, and possibly high blood pressure was not monitored according to the physician ordered parameters. In addition, the facility did not implement the Medical Director (MD) orders as they pertained to the pharmacist's recommendations. Resident identifiers: 12 and 35.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that residents who received psychotropic drugs were not prescribed the medication unless necessary to treat a specific condition as diagnosed in the clinical record; and residents who used psychotropic drugs received gradual dose reductions, monitoring, and behavioral interventions in an effort to discontinue the medication. Specifically, for 1 out of 28 sampled resident, the Medical Director (MD) ordered dose adjustments of psychotropic medications that were not implemented and doses of psychotropic medications were missed. Resident identifier: 12.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility did not ensure residents were free of any significant medication errors. Specifically, for 1 out of 28 sampled residents, a resident was administered the wrong medication during the medication administration task observation. Resident identifier: 41.

Inspectors wroteBased on observation and interview, it was determined, 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 food items in the walk-in refrigerator were open to air.

Inspectors wroteBased on interview and record review it was determined, for 8 of 35 sampled residents, that the facility failed to ensure the residents were free from abuse and neglect. Specifically, the facility did not provide protection to ensure that residents were free from verbal and physical abuse from other residents. Resident identifiers: 10, 14, 17, 32, 35, 43, 47, and 59.

Inspectors wroteBased on interview and record review it was determined, for 2 of 35 sampled residents, that the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice. Specifically, full and complete neuro checks were not performed on three separate occasions for two residents who suffered falls with head injuries, and a resident was not taken to the hospital upon being found unresponsive. Additionally, it was discovered this resident had a hip fracture three days later. Resident identifiers: 10 and 32.

Inspectors wroteBased on observation, interview and record review, it was determined for 1 of 35 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, one resident's care plan was not updated, the resident was not monitored more frequently, moved closer to the nurses' station, nor moved to the third floor for better supervision. Also, the facility failed to keep the facility in good repair and caused the resident to have a fall. Resident identifier: 18.

Inspectors wroteBased on interview and record review it was determined for 4 of 35 sampled residents that the facility did not ensure alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency (SA) and that the results of all investigations were reported to the SA within 5 working days of the incident. Specifically, alleged violations were not reported to Adult Protective Services, injuries of unknown origin were not reported to the SA, five day follow ups were not reported to the SA, and alleged violations were not reported timely and completely. Resident identifiers: 10, 17, 32, and 47.

Inspectors wrote3. Resident 17 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with behavioral disturbance, history of transient ischemic attack, major depressive disorder with psychotic features, muscle weakness, cognitive communication deficit, and pseudobulbar affect. Resident 17's medical record was reviewed on 2/18/2020. A progress note for resident 17 dated 10/9/19 revealed the following: [Resident 17] was in the dining room getting ready for dinner and accidentally bumped into [resident 26's] WC (wheelchair) with his WC. [Resident 26] jumped up and pushed [resident 17's] face into the wall, and put [resident 17] into a choke hold around his neck, causing a small scratch on the right side of [resident 17's] neck, with some redness. [...]

Inspectors wroteBased on observation, interview, and record review it was determined, for 8 of 35 sample residents, that 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, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, residents' care plans were not updated with interventions to prevent falls, elopement, wondering into other resident room, invading personal space, intimidating others, verbal altercations, physical alterations, and inappropriate behavior with staff . Resident identifiers: 18, 26, 33, 35, 38, 40, 43, and 59.

Inspectors wroteBased on interview and observation, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, multiple residents sustained abuse from other residents, one resident sustained multiple falls, did not adequately train agency staff, and residents did not receive adequate behavioral health services.

Inspectors wrote7. Resident 59 was admitted to the facility on [DATE] with diagnoses which included generalized anxiety disorder, impulse disorder, depression, dementia behavioral disturbance, chronic pain, dysphagia, muscle weakness, cognitive communication, concussion with loss of consciousness, psychotic disorder with delusions, transient cerebral ischemic, impulsiveness, and traumatic brain injury. On 2/19/2020 resident 59's medical record was reviewed. Resident 59 exhibited inappropriate behavior with other residents on several occasions: a. On 2/8/19 at 7:32 PM, a nurse note revealed that a CNA reported resident 59 was observed yelling and attempting to strike another resident. CNA was able to deescalate and redirect resident 59. b. On 2/9/19 at 12:00 AM, a nurse note revealed that resident 59 had verbal exchange with another resident. c. [...]

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, staff were in the kitchen without hairnets, dietary staff were not changing their gloves after touching soiled items.

Inspectors wroteBased 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 must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there was, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Specifically, the facility's resources were not included in the assessment.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure the medical director was responsible for implementation of resident care policies and the coordination of medical care in the facility. Specifically, the Medical Director was not informed of abuse in the facility, multiple falls, the use of physical restraints for 1 resident without notification or a physician's order, delay in identifying a hip fracture, Accident hazards, multiple suicide attempts by one resident

Inspectors wroteBased on interview, observation and record review it was determined that the facility failed to maintain a Quality Assessment and Assurance (QAA) Committee that identified issues with respect to which Quality Assessment and Assurance activities were necessary. In addition, the QAA committee did not develop and implement appropriate plans of action to correct identified quality deficiencies. Specifically, deficient practices identified during the survey included abuse, use of restraints, quality of care, accident hazards, adequate staffing, and behavioral health services. Findings Include: 1. Based on interview and record review it was determined, for 8 of 35 sampled residents, that the facility failed to ensure the residents were free from abuse and neglect. [...]

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 35 sampled residents, that the facility did not ensure that each resident was free from any physical restraint imposed for the purpose of discipline or convenience and not required to treat the resident's medical symptoms. Specifically, a resident was physically restrained by facility staff with no training to staff, no investigation, and no physician order or physician notification. Resident identifier: 26.