Monument Healthcare Cottonwood Creek

Inspectors wroteBased on observation, interview, and record review the facility did not, for 2 of 26 sampled residents, ensure that the environment remained as free of accident hazards as possible, and that each resident received adequate supervision and assistance device to prevent accident. Resident identifiers: 35 and 56.

Inspectors wroteBased on observation and interview, it was determined that the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, soiled ceiling tiles and dusty air vents were observed throughout the facility, the west hall was found to have a urine-like odor, and the facility environment was in disrepair.

Inspectors wroteBased on observation, interview, and record review, it was determined that for 6 of 26 sampled residents, that the facility did not ensure that all allegations of abuse or neglect were reported to the State Survey Agency (SSA). In addition, the facility did not ensure the results of all investigations of alleged abuse and neglect were reported to the necessary officials, including the SSA, within 5 working days. Due to the facility's identification of missed reporting of reportable allegations and their subsequent implementation of corrective measures, as well as the facility's current compliance in this regulatory area, this deficiency was determined to be past noncompliance. The facility achieved compliance on 3/15/2024. Resident identifiers: [...]

Inspectors wroteBased on interviews and record review, it was determined for 2 out of 26 sampled residents, the facility did not ensure that each resident was free from abuse. Specifically, a staff located a female resident standing in front of a male resident, in the male resident's room. The male resident was seated in a wheelchair and had a hand up the shirt of the female resident, touching the female resident's breast. Both residents have significant cognitive impairment. Due to the facility's identification of abuse, subsequent corrective measures, and the facility's current compliance in this regulatory area, the deficiency was determined to be past noncompliance and the facility achieved compliance on 3/25/2024. Resident identifiers: [...]

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 26 sampled residents, that the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming. Specifically, a resident with severely impaired cognitive skills had long fingernails with brown substance under the fingernails. Resident identifier: 28.

Inspectors wroteBased on interview and record review, it was determined, for 1 of 26 sampled residents, that the facility failed to ensure PRN (as needed) orders for psychotropic drugs were limited to 14 days, unless the attending physician or prescribing practitioner believes that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Specifically, a PRN order for Ativan was ordered for more than 21 days. Resident identifier: 16.

Inspectors wroteBased on observation, interview, and record review, it was determined, 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, for 3 out of 26 sampled residents, residents that had multiple falls with injuries were not provided interventions or adequate supervision to prevent falls from occurring. A resident had a fall that resulted in a left hip fracture and the resident was hospitalized . In addition, a resident had a fall resulting in a hematoma to the forehead. Resident identifiers: 32, 48, and 53.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, for 1 out of 26 sampled residents, a resident who had experienced a significant weight loss did not have interventions put in place to prevent further significant weight loss. Resident identifier: 53.

Inspectors wroteBased on observation and interview, it was determined, the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life. Specifically, staff members were observed standing over residents while the residents were provided with meal consumption assistance. In addition, on one occasion a resident was observed to be seated with other residents who were consuming their meal, while the resident was not provided with eating assistance timely.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 7 out of 26 sampled residents, the facility did not ensure implementation of a resident's care plan interventions regarding limited range of motion and contractures; for three residents, the facility did not update and implement interventions for fall prevention; and, for three residents, the facility was unable to demonstrate development and implementation of dementia related care plans. Resident identifiers: 3, 15, 16, 32, 45, 48, and 53.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility did not ensure residents who displayed or were diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Specifically, for 3 out of 26 sampled residents, the facility was unable to demonstrate development and implementation of interventions for managing residents' dementia with behavioral disturbances. Resident identifiers: 3, 16, and 45.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance with F689 and F880 which were cited within the facility's 2018 and 2019 recertification survey. Also, the facility was found to be in non-compliance with F656 and F744 which were cited within the facility's 2019 recertification survey.

Inspectors wroteBased on observation and interview, it was determined, 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, observations were made of staff administering medications without following hand hygiene protocols, staff were observed to utilize communal vital signs equipment without sanitizing the equipment between resident usage, and residents were observed to consume food items off of other residents dirty meal trays and other residents were observed to consume food from the facility trash cans. Resident identifiers: 10, 16, 25, 33, 35, 40, 45, and 48.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure the resident's medical record included documentation that indicates, at a minimum, the following: that the resident or resident representative was provided education regarding the benefits and potential risks associated with Coronavirus Disease-2019 (COVID-19) vaccine; each dose of COVID-19 vaccine administered to the resident; or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Specifically, for 2 out of 26 sampled residents, the facility did not keep documentation within the residents' medical record regarding the residents' COVID-19 vaccination refusal, acceptance, or education of the benefits and potential risks associated with the COVID-19 vaccination. Resident identifiers: 10 and 43.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility did not ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion or to prevent further decrease in range of motion. Specifically, for 1 out of 26 sampled residents, a resident with limited range of motion (ROM) was not provided with the prescribed interventions for prevention of further decreased range of motion. Resident identifier: 15.

Inspectors wroteBased on interview and record review, it was determined, the irregularities noted by the pharmacist during the drug regimen review were not reported to the attending physician and the facility's Medical Director (MD) and Director of Nursing (DON), and these reports must be acted upon. Specifically, for 2 out of 26 sampled residents, recommendations were not acted upon timely after the pharmacist made the recommendation. Resident identifiers: 4 and 18.

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 26 sampled residents, a resident's hypertensive medications were not held when the blood pressure (BP) measurements were outside of the physician's ordered parameters. In addition, the Medical Director (MD) was not notified as ordered by the physician when the resident's BP measurements were outside of the physician's ordered parameters. Resident identifier: 4.

Inspectors wroteBased on interview and record review, it was determined, the facility did not obtain laboratory (lab) services to meet the needs of its residents. Specifically, for 1 out of 26 sampled residents, a resident had a physician's order for a blood draw to measure valproic acid levels and the lab was not completed. Resident identifier: 40.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that each resident's medical record included documentation that indicated that the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations; and that the resident either received the influenza and pneumococcal immunizations or did not receive the influenza and pneumococcal immunizations due to medical contraindications or refusal. Specifically, for 2 out of 26 sampled residents, the facility did not keep documentation within the residents' medical record regarding the residents' influenza consent status or education of the benefits and potential risks associated with the immunization. Resident identifiers: 15 and 43.

Inspectors wroteBased on observation, interview and record review it was determined, for 10 of 32 sample residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing 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, residents waited for over 20 minutes to be served breakfast and staff members complained of not enough staff for the Journey's unit. Resident identifiers: 4, 8, 25, 34, 35, 38, 44, 48, 49, and 61.

Inspectors wroteBased on observation and interview it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, one multi-dose vial of Tuberculin Purified Protein Derivative was expired and available for resident use, the pharmacy provided emergency kit (Ekit) was not locked, and a treatment cart on the unit was not locked and secured. Resident Identifiers: 54, 61, 163, and 164.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 32 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 had a gait belt around her waist that was secured to her wheelchair. Resident identifier: 28.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 32 sampled residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, a resident experienced falls and did not have a care plan updated. Resident identifier:

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 32 sampled residents, that the facility did not provide appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. Specifically, a resident did not receive assistance with eating for 19 minutes and staff did not put in her hearing aides. Resident identifier: 11.

Inspectors wroteBased on observation, interview, and record review it was determined, for 2 of 32 sampled residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, a resident with a hip fracture had a delay in treatment. Resident identifiers: 11 and 162.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 32 sampled residents, that the facility did not ensure that each resident received adequate supervision to prevent accidents. Specifically, a resident sustained 17 falls without adequate interventions developed to prevent falls. Resident identifier: 4.

Inspectors wroteBased on observation, interview, and record review it was determined, for 9 of 32 sampled residents, that the facility did not ensure a resident who was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his highest practicable physical, mental and psychosocial well-being. Specifically, a resident was continually yelling out in the Journey's unit and disrupting other residents. Resident identifiers: 4, 8, 25, 35, 38, 44, 48, 49, and 61.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 32 sampled residents, that the facility did not establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, a resident's urinary catheter bag was touching the floor without a barrier. Resident identifier: 47.