Msm Brigham City LLC

Inspectors wroteBased on interview and record review it was determined, for 2 out 25 sampled residents, that the facility did not ensure that the resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections (UTI). Specifically, a resident developed a UTI following the use of a PureWick, which had been implemented without a physician's order or usage instructions. In addition, a resident had no follow-up after a urine culture was contaminated. This resulted in harm for resident 56. Resident identifiers: 3 and 56.

Inspectors wroteBased on observation, interview, and record review it was determined the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the dishmachine was not at the required temperature for sanitation, there were soiled areas in the kitchen, and domes over food were tarnished with a white substance.

Inspectors wroteBased on observation and interview, it was determined for 3 of 25 sampled residents, the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. Specifically, insulin pens were not dated with an open date or had expired past 28 days. Resident identifiers: 1, 3, and 15.

Inspectors wroteBased on interview and record review, it was determined for 5 out of 25 sampled residents that the facility did not file in the resident's clinical record laboratory reports. Specifically, urine culture and blood laboratory results were missing from the medical records for three residents, and the result for one resident's clotted laboratory sample was not located from the medical record. Resident identifiers: 3, 7, 8, 33, and 56.

Inspectors wroteBased on interview and record review it was determined the facility did not employ a full-time, designated person to serve as the director of food and nutrition services. Specifically, the facility did not have a qualified food service director.

Inspectors wroteBased on observation, interview, and record review it was determined, for 4 of 25 sampled residents, each resident did not receive food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained about the food temperatures and palatability, the test tray was not palatable, and resident council minutes revealed concerns regarding food. Resident identifiers: 11, 21, 35 and 39.

Inspectors wroteBased on interview and record review it was determined for 3 out of 25 sampled residents, that the facility did not maintain medical records on each resident that were complete and accurately documented. Specifically, a resident had conflicting Metoprolol Tartrate and Metoprolol Succinate documentation, a resident had conflicting International Normal Ratio (INR) laboratory orders, and a resident had a diagnosis of diabetes mellitus for the use of intravenous antibiotics. Resident identifiers: 6, 14, and 34.

Inspectors wroteBased on interview and record review it was determined, for 1 of 25 sampled residents, that the facility did not immediately consult with the resident's physician when there was a need to alter treatment. Specifically, the physician was not notified when a resident's Donepezil and Levothyroxine was held for multiple days due to unavailability. Resident identifier: 8.

Inspectors wroteBased on interview and record review it was determined, for 1 of 25 sampled residents, that the facility did not ensure that when a resident was transferred that the transfer was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider, and a copy of the notice of transfer was sent to the Office of the State Long-Term Care Ombudsman. Specifically, the resident's medical records did not have documentation of what information was provided to the receiving health care provider when they were transferred to the emergency room (ER) and no documentation could be found to indicate that the Ombudsman was notified of the transfer. Resident identifier: 8.

Inspectors wroteBased on interview and record review it was determined, for 2 of 25 sampled residents, that the facility did not provide each resident adequate supervision to prevent accidents. Specifically, a resident sustained multiple injuries while operating his power wheelchair after therapy evaluated the resident as needing supervision while operating the wheelchair. In addition, another resident was not provided two person assistance during repositioning for a brief change and sustained a fall. Resident identifiers: 4 and 33.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 25 sampled residents, that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, the resident's Levothyroxine and Donepezil were not available from the pharmacy for administration. Resident identifier: 8.

Inspectors wroteBased on interview and record review it was determined, for 1 of 25, the facility did not promptly notify the ordering physician of laboratory results that fall outside of clinical reference ranges. Specifically, the physician was not notified after a laboratory specimen was clotted and not completed as ordered. Resident identifier: 33.

Inspectors wroteBased on interview and record review, it was determined for 1 out of 25 sampled residents the facility did not file in the resident's clinical record radiologic reports. Specifically, a resident's head Computed Tomography (CT) results were not in the medical record. Resident identifier: 14.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all residents remained free from abuse, neglect, and misappropriation of property. Specifically, for 1 out of 21 sampled residents, a dependent resident was left unattended in the shower for hours while the Certified Nurse Assistant (CNA) left their scheduled shift early. Resident identifier: 16.

Inspectors wroteBased on interview and record review, 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 were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA) and Adult Protective Services (APS). In addition, the facility did not ensure that all investigations were reported to the SSA within 5 working days of the incident. Specifically, for 4 out of 21 sampled residents, notification to the SSA and APS was not within 2 hours after allegations of abuse, neglect, and injuries of unknown origin were identified and an investigation was reported to the SSA 7 working days of the incident. Resident identifiers: 16, 23, 89, and 90.

Inspectors wroteBased on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. In addition, the facility did not ensure that all drugs and biologicals were stored under proper temperature controls. Specifically, opened insulin injector pens were not labeled with open dates and the insulin injector pens were in the medication cart available for resident use. In addition, the medication refrigerator was found to have low temperatures not compatible with medication storage.

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, there were numerous undated and unlabelled items in both the walk-in refrigerator and freezer, items stored on the floor in both the walk-in refrigerator and freezer, and there was a significant layer of dust on vents located above food preparation and plating areas.

Inspectors wroteBased on observation, interview, and record review, the facility did not 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, including Coronavirus Disease 2019 (COVID-19). Specifically, for 2 out of 21 sampled residents, during a COVID-19 outbreak the facility staff did not dispose of their used Personal Protective Equipment (PPE) correctly, Transmission Based Precautions (TBP) and quarantine was discontinued for a COVID-19 positive resident after only six days of isolation, and staff face masks were observed worn down below the nose and mouth. Resident identifiers: 17 and 133.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the interdisciplinary team had determined that the resident's right to self administer medications was clinically appropriate. Specifically, for 1 out of 21 sampled residents, the Registered Nurse (RN) was observed to leave a residents medications at the bedside in a medication cup and the resident had not been evaluated to determine if they were safe to self administer medications. Resident identifier: 19.

Inspectors wroteBased on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment that they prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. Specifically, for 1 out of 21 sampled residents, an allegation of neglect was made and the alleged perpetrator was not suspended pending the investigation and was allowed access to the resident/victim. Resident identifier: 16.

Inspectors wroteBased on interview and record review, the facility did not ensure that the resident environment remains as free of accident hazards as was possible and that each receives adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 21 sampled residents, facility staff attempted to transfer a resident from her bed to her wheelchair using a Hoyer lift without properly securing the Hoyer straps. Resident identifier:

Inspectors wroteBased on interview and record review, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 21 sampled residents, a residents medications were not administered as ordered by the physician due to the medications not being available by the pharmacy. Resident identifier: 4.

Inspectors wroteBased on interview and record review, the facility did not ensure the attending physician documented in the resident's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address the irregularity. If there was to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. Specifically, for 2 out of 21 sampled residents, pharmacy recommendations including the physician's documentation was not included in the resident's medical record. Resident identifier: 1 and 4.

Inspectors wroteBased on interview and record review, 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 21 sampled residents, the provider was not notified per the physician's order when a resident's blood glucose (BG) and systolic blood pressure (SBP) were outside of the physician's ordered parameters. In addition, a resident's long acting insulin was held when it should have been administered per the sliding scale physician's order. Resident identifier: 4.

Inspectors wroteBased on interview and record review, the facility did not obtain laboratory services to meet the needs of its residents. Specifically, for 1 out of 21 sampled residents, the facility did not obtain a specimen for a lab that was ordered by the provider. Resident identifier: 1.

Inspectors wroteBased on interview and record review, the facility did not ensure that the antibiotic stewardship program that included antibiotic use protocols and a system to monitor the antibiotic use were implemented. Specifically, for 1 out of 21 sampled residents, a resident was prescribed and completed an antibiotic for a suspected urinary tract infection (UTI) even after the urine culture determined no bacterial growth. Resident identifier: 22.

Inspectors wrote1. Screening of staff and visitors prior to entering the facility: On 2/24/22 at 4:41 PM, a interview was conducted with the facility Administrator (ADM). The ADM stated that the Administrator in Training (AIT) was filling in as the Business Office Manager (BOM) and then they hired another staff for the BOM position. The ADM stated that the AIT stayed on for a week afterwards, but she was not getting paid the week of January 18th, 2022, but she was at the facility. The ADM stated that the AIT was signing in for screening and she would come and go as needed. The ADM stated that she did not track the AIT's hours at the facility. On 2/24/22 at 5:12 PM, an interview was conducted with the Corporate Resource Nurse (CRN) 2. CRN 2 stated that the AIT did just come and go because she was an AIT. CRN 2 stated that the AIT should still be screening when she came into the facility. [...]

Inspectors wroteResident 6 was admitted to the facility on [DATE] with diagnoses that included Down Syndrome, encephalopathy, respiratory failure, obesity, and depression. On 2/22/22 at 12:13 PM, an interview was conducted with resident 6. Resident 6 stated that there were two residents who said mean things to her, naming resident 4 and resident 14. Resident 6 stated that the other residents told her to shut up and go to her room when they were at activities. Resident 6 stated that she had fought with her family member (FM 2) who was a resident in another area of the facility, who could visit resident 6 as desired. Resident 6 stated that she was kept in another room overnight, away from her own room. Resident 6 stated that FM 2 had asked her for money. On 2/23/22 at 2:10 PM, resident 6's family member (FM) 1 stated that resident 6 had fought with FM 2 for years. [...]

Inspectors wroteBased on interview and record review, it was determined for 1 of 25 sample residents, that the facility did not ensure that all residents were free from involuntary seclusion. Involuntary seclusion was defined as separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident's will, or the will of the resident representative. Specifically, a resident was taken away from a group of residents to her room, and then placed in an unfamiliar room overnight against her will and without the knowledge of the resident's Power of Attorney. The deficient practice identified was found to have occurred at a harm level. Resident identifier: 6.

Inspectors wroteBased on observation, interview and record review it was determined the facility did not store, prepare and distribute food in accordance with professional standards for food service safety. Specifically, the dish machine wash temperature was not meeting the manufacture requirements and there were soiled areas in the kitchen.

Inspectors wroteBased on interview and record review it was determined that the facility did not maintain evidence demonstrating the results of all grievances for a period of no less than 3 years from the issuance of the grievance decision. Specifically, facility grievance records could not be located prior to November 2021.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that the abuse policies and procedures were implemented to prevent abuse for 3 of 25 sample residents. Specifically, one resident experienced physical, verbal, financial, and emotional abuse and was involuntarily secluded. Resident identifiers: 4, 6, and 14.

Inspectors wroteBased on observation, interview and record review it was determined, for 3 of 25 sampled residents, that the facility did not ensure that medication error rates were not 5 percent or greater. Observations of 34 medication opportunities, on [DATE], revealed 5 medication errors which resulted in a 14.71% medication error rate. Specifically, two residents received Levothyroxine with meals, a full dose of Miralax was not administered, Fiber capsules were administered without verification of dosage, and a Symbicort inhaler was administered without verification of the medication expiration. Resident identifiers: 9, 12, and 125.

Inspectors wroteBased on observation, record review and interview the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility was found to be in non-compliance with F880, which was cited at an Immediate Jeopardy, scope and severity of L. In addition, one resident was abused and involuntarily secluded with the permission of management, which was cited at an Immediate Jeopardy, scope and severity of H. Resident identifiers: 4,6, 14, 125, and 127.

Inspectors wroteBased on interview and record review, the facility did not ensure that 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 F880, which was cited at an Immediate Jeopardy, scope and severity of L. In addition, F600, abuse was cited at an Immediate Jeopard, scope and severity of H. Resident identifiers: 6, 125, and 127.

Inspectors wroteBased on observation, interview and record review it was determined the facility did not follow policy and procedures for residents with COVID-19 vaccination exemptions. Specifically, staff with COVID-19 vaccination exemptions were not wearing personal protective equipment according to the facility's policy and procedures.

Inspectors wroteBased on observation, interview and record review it was determined, for 2 or 25 sampled residents, that the facility did not ensure that the interdisciplinary team (IDT) had determined that the resident's right to self administer medications was clinically appropriate. Specifically, two residents were not evaluated to determine if they were safe to self administer medications. Resident identifiers: 4 and 125.

Inspectors wroteBased on interview and record review it was determined, for 1 of 25 sample residents, that the facility did not promote and facilitate the resident's self-determination through support of the resident's choice. Specifically, the resident requested that their breakfast meal tray be left at the bedside with the lid left on and the kitchen staff told the resident no, that it would be returned to the kitchen if not eaten within an hour. Resident identifier: 125.

Inspectors wroteBased on interview and record review it was determined, for 1 of 25 sample residents, that the facility did not immediately consult with the resident's physician when there was a change in the resident's physical, mental, or psychosocial status or when a decision to transfer the resident from the facility was made. Specifically, the resident was transferred to the local hospital emergency room (ER) for evaluation and treatment of back pain and the physician was not notified. Resident identifier: 22.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 25 sample residents, that the facility did not ensure that the resident had the right to personal privacy and confidentiality of their personal and medical records. Specifically, a licensed nurse was observed to provide a visitor with a resident's personal health information without determining who the visitor was first and if they had access to that information. Resident identifier: 127.

Inspectors wroteBased on interview and record review it was determined, for 1 of 25 sample residents, that in response to allegation of abuse the facility did not ensure that all alleged violations involving abuse were immediately, but no later than 2 hours after the allegation was made, if the event that caused the allegation involved abuse. This involved reporting to other officials in accordance with State law. Specifically, the facility did not report when a resident was involuntarily secluded. In addition, the facility did not report within 2 hours to the State Survey Agency when same resident was physically and verbally abused by a family member. Other officials were not contacted regarding both incidents. Resident identifier: 6.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 25 sample residents, that in response to allegations of abuse the facility did not have evidence that all alleged violations were thoroughly investigated to prevent further potential abuse. In addition if the alleged violation was verified appropriate corrective action was not taken. Specifically, a resident that was involuntarily secluded in a room that was unfamiliar to her and an investigated was not conducted regarding potential abuse. In addition, the same resident was verbally and physically abused by a family member and a thorough investigated was not conducted to prevent possible further abuse. Resident identifier: 6.

Inspectors wroteBased on interview and record review it was determined, for 1 of 25 sample residents, that the facility did not ensure that the transfer was documented in the resident's medical record and included the basis for the transfer, that the services were attempted and could not be provided in the facility, that the transfer was made by the resident's physician, and that the receiving provider was provided all the necessary information to ensure a safe and effective transition of care. Specifically, the resident was transferred to the local hospital emergency room (ER) for evaluation and treatment of back pain without a physician order for the transfer and no documentation could be found of a transfer assessment or documentation that was provided to the receiving provider. Resident identifier: 22.

Inspectors wroteBased on interview and record review it was determined that the facility did not develop and implement a comprehensive person-centered care plan for 1 of 25 sample residents, consistent with the resident right that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, activities of daily living function/rehabilitation potential, urinary incontinence and indwelling catheter, nutritional status, and dehydration/fluid maintenance were not developed as required. Resident identifier: 6.

Inspectors wroteBased on observation, interview and record review, the facility did not receive registry verification for a nurse aide prior to allowing the staff member to serve as a nurse aide.

Inspectors wroteBased on observation, interview and record review it was determined for 1 of 25 sample residents that the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, a resident with intellectual and behavior issues was not evaluated by or treated by a Licensed Clinical Social Worker (LCSW). Resident identifier 6.

Inspectors wroteBased on interview and record review it was determined that the facility did not provide, for 1 of 25 sample residents, specialized rehabilitative services such as physical therapy and occupational therapy that were required in the resident's comprehensive plan of care. Specifically, a resident was not provided assessed specialized rehabilitation. Resident identifier 6.