Monument Healthcare Taylorsville

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents. Specifically, for 1 out of 41 sampled residents, one resident sustained a second-degree burn from a heat therapy treatment and will be cited at a harm level. Resident identifier: 76.

Inspectors wroteBased on observation and interview, the facility did not ensure that drugs and biologicals were labeled in accordance with accepted professional principles and stored in locked compartments. Specifically, observations were made of resident medications left unlocked and unattended on top of the medication cart, a multidose vial of insulin was available for use past its expiration date, and a multidose vial of tuberculin did not contain an open date for the vial. Resident identifiers: 7 and 70.

Inspectors wroteBased on interview and record review, the facility did not ensure that the resident had the right to manage their financial affairs and included the right to know, in advance, what charges the facility imposed against a resident's personal funds. Specifically, for 1 out of 41 sampled residents, a resident was not informed in advance that the facility was going to charge against their personal funds the supplemental insurance premiums. Resident identifier: 54.

Inspectors wroteBased on interview and record review, the facility did not ensure that the financial record was available to the resident through quarterly statements and upon request. Specifically, for 1 out of 41 sampled residents, a resident's quarterly statements were not provided to the resident or their personal representative and Power of Attorney (POA). Resident identifier: 54.

Inspectors wroteBased on interview and record review, the facility did not ensure that charges were not imposed against the personal funds of a resident for any item or service for which payment was made under Medicaid or Medicare. Specifically, for 1 out of 41 sampled residents, a resident's Medicaid funded insurance premiums were deducted from the resident's personal funds account and not from the facility Cost of Care (COC). Resident identifier: 54.

Inspectors wroteBased on interview and record review, the facility did not inform Medicaid-eligible residents when changes were made to the items and services provided. Specifically, for 1 out of 41 sampled residents, changes were made to the residents Medicaid funded supplemental vision and dental insurance and the facility did not provide notice to the resident of the changes timely. Resident identifier: 54.

Inspectors wroteBased on interview and record review, the facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the health or safety of an individual in the facility is endangered; the licensee ceases to operate the facility; the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility; the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; or the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. Specifically, for 2 out of 41 sampled residents, two residents were inappropriately discharged from the facility after going on leave of absence. Resident identifiers: 115 and 137.

Inspectors wroteBased on interview and record review, the facility did not provide the necessary care and services to ensure that the resident was given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living. Specifically, for 1 out of 41 sampled residents, a resident was not provided assistance with showers per their preferences and as outlined in their shower schedule. Resident identifier: 116.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 41 sampled residents,an assessment of the resident's condition and monitoring for complications before and after dialysis treatments were not completed. Resident identifier: 13.

Inspectors wroteBased on observation and interview, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 2 out of 41 sampled residents, a resident receiving medication to prevent infection and a resident receiving medication for diabetes mellitus did not have those medications available from the pharmacy for administration. Resident identifiers: 2 and 49.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was defined as any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, for 1 out of 41 sampled residents, blood pressure medications were administered outside of parameters and professional standards of care. Resident identifier: 13.

Inspectors wroteBased on interview and record review, the facility did not provide or obtain outside resources for routine or emergency dental services to meet the needs of the resident. Specifically, for 1 out of 41 sampled residents, a resident that asked to see the dentist for a broken tooth did not have those services arranged. Resident identifier: 49.

Inspectors wroteBased on observation and interview, the facility did not store food in accordance with professional standards for food service safety. Specifically, the residents personal food fridge had two food containers that were not labeled with a date.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the use of outside resources. Specifically, for 1 out of 41 sampled residents, a referral for a urology consultation was not made for a resident. Resident identifier: 70.

Inspectors wroteBased on observation, interview, and record review it was determined that for 2 of 7 sampled residents, that the facility did not ensure that the resident environment remains as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not ensure that a resident transported to a dialysis appointment was properly secured with a seatbelt, and subsequently sustained fractures of both of his legs. In addition, the facility did not ensure that a resident's call light was within reach and the resident reached for the call light, fell out of bed, and fractured his hip. This will be cited at a HARM. Resident Identifiers: 4, 7.

Inspectors wroteBased on interview and record review, it was determined, that for 2 of 7 sampled residents, that 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, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hour if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. [...]

Inspectors wroteBased on interview and record review it was determined, for 1 of 7 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident with heart failure had hospital discharge orders for daily weights, the order was not implemented at the facility until 6 days after the resident was admitted . Resident Identifier: 1.

Inspectors wroteBased on interview and record review, it was determined that the facility did not consider the views of a resident or family group and act promptly upon the grievances and the recommendations of such groups concerning issues of resident care and life in the facility. Specifically, the facility did not follow up on grievances filed by residents.

Inspectors wroteBased on interview and record review, the facility did not transmit to the Centers for Medicare/Medicaid (CMS) System information for each resident contained in the Minimum Data Set (MDS) within 7 days after completion. Resident identifiers: 2, 4, 28, 38, 48, 61, and 78.

Inspectors wroteBased on observation, interview, and record review, it was determined, the facility did not ensure that each resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Specifically, for 3 out of 40 sampled residents, a resident with bilateral hand contractures was not being provided the ordered device to hold in the contracted hand during the day for comfort and prevention. In addition, residents did not received RNA (Restorative Nursing Services). Resident identifiers: 22, 68 and 73.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility did not provide food prepared by methods that conserve nutritive value, flavor, and appearance or palatable, attractive, and at a safe temperature. Specifically, 13 residents complained of food to surveyors, numerous residents filed grievances about the quality of the food served, multiple resident council notes complained of food quality, and a test tray pulled by surveyors was not palatable. Resident identifiers: 1, 2, 6, 12, 27, 41, 53, 54, 55, 61, 71, 86, and 156.

Inspectors wroteBased on interview and record review, it was determined for 1 of 40 sampled residents, that the facility did not inform the resident in language that could be understood, of the care to be furnished, of the risks and benefits of the proposed care, of the treatment and treatment alternatives or options and to choose the option that he or she prefers. Specifically, one resident was not aware of the change in their diet order. Resident identifier: 68.

Inspectors wroteBased on interview and record review, it was determined for 1 of 40 sampled residents, that the facility did not inform the resident in language that could be understood, of the care to be furnished, of the risks and benefits of the proposed care, of the treatment and treatment alternatives or options and to choose the option that he or she prefers. Specifically, one resident was not aware of the change in their diet order. Resident identifier: 68.

Inspectors wroteBased on interview, observation and record review, 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, a resident requiring a specialized diet was not allowed to bring in his mini refrigerator to store his food. Resident identifier: 68.

Inspectors wroteBased on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that a resident who received psychotropic drugs were not given these drugs unless the medication was to treat a specific condition as diagnosed and documented in the clinical record. Specifically, a resident who was prescribed a psychotropic medication was given the medication daily with out adequate monitoring. Resident identifier 18.