Inspection Reports for Monument Rehabilitation and Care Center

The complaint alleged failure to change interventions to protect residents from abuse, failure to ensure medications were appropriately used, and failure to ensure staff had appropriate credentials. The investigation substantiated the abuse intervention and staff credential allegations but found no medication issues.

The facility failed to implement effective interventions to prevent recurrent resident-to-resident abuse and failed to ensure a nursing assistant was active on the Nurse Aide Registry as required. Medication use was found to be appropriate with no deficiencies cited.

The complaint included allegations that the facility failed to ensure assessments were complete, failed to ensure staff were trained to meet residents' needs, and failed to provide care and treatment for bladder elimination. The first two allegations were not substantiated; the third was substantiated.

The investigation found no violation regarding incomplete assessments or staff training. However, the allegation of failing to provide care and treatment for bladder elimination was substantiated due to improper peri-care and catheter care for one resident. The facility was cited accordingly.

The complaint alleged failure to protect residents from abuse and failure to provide care and treatment for bladder elimination. The facility was found in compliance with these allegations after investigation.

The investigation found the facility in compliance with regulatory requirements regarding abuse and bladder care. However, a deficiency was identified related to failure to develop, review, and revise the comprehensive care plan for one resident with hypoglycemic episodes.

The complaint investigation was triggered by allegations that the facility failed to change interventions after residents were identified at risk for falls and failed to submit investigations within 5 working days. The investigation confirmed these allegations and also found failure to report resident-to-resident altercations to the State Agency as required.

The facility failed to change interventions after residents had been identified at risk for falls, specifically for Resident 52, and failed to notify the Primary Care Provider and family of resident falls. The facility also failed to submit investigations of resident-to-resident altercations to the State Agency within required timeframes. Additionally, the facility failed to identify causal factors for falls and implement interventions to prevent injury after identifying residents at risk for falls, affecting Residents 50 and 52.

The complaint investigation included allegations that the facility failed to evaluate causal factors for falls, failed to ensure staff were trained to meet residents' needs, and failed to ensure written investigations were complete and accurate. The investigation found deficiencies related to staff training and competency, but no violation related to fall causal factor evaluation or investigation accuracy.

The facility was found deficient in multiple areas including staff competency, resident care, environment, infection control, medication management, emergency preparedness, and life safety code compliance. Specific issues included improper resident transfers resulting in injury, failure to maintain accurate resident weights, inadequate activity programming, failure to follow isolation and hand hygiene protocols, and environmental maintenance deficiencies.

The facility was found in violation of multiple licensure regulations related to care and treatment, including charge nurse requirements, prevention and healing of pressure sores, accident prevention, and comprehensive care planning. The violations were documented in a CMS-2567 report dated September 7, 2017, and included failures in resident rights, environmental services, medication management, and staff training.

The complaint investigation included allegations of failure to protect residents from abuse, failure to submit investigations timely, failure to provide care to prevent pressure sores, medication errors, failure to notify appropriate parties of change of condition, and failure to follow plans of care for residents at risk for falls. Some allegations were substantiated with deficiencies cited.

The facility was found not in compliance with multiple regulatory requirements including resident care, medication administration, infection control, environment maintenance, emergency preparedness, and life safety code compliance. Deficiencies included failure to protect residents from abuse, incomplete investigations, inadequate care planning, medication errors, privacy violations, and environmental hazards.

The facility was found not in substantial compliance with participation requirements, resulting in the imposition of a civil money penalty due to deficiencies constituting a level of actual harm or above.

The complaint alleged failures in catheter care to prevent infections, housekeeping, pest control, care during change in condition, fall intervention changes, and evaluation of fall causal factors. The investigation substantiated failures in catheter care, fall intervention changes, and evaluation of fall causal factors.

The facility was found to be in violation of several federal and state regulations related to failure to maintain urinary catheters to prevent infections, failure to revise fall interventions after residents were identified at risk, and failure to evaluate causal factors for falls. The facility was found to be in compliance with housekeeping and pest control programs and providing care when there was a change in condition. Documentation deficiencies were noted in catheter care and fall prevention interventions.

The complaint investigation substantiated violations related to failure to follow fall interventions and failure to protect residents from abuse, including verbal intimidation by staff. The facility was found compliant on other allegations such as call system response, restraint use, investigation submission, and noise control.

The facility was found compliant with call notification systems, restraint use, investigation submission, and noise control. However, violations were found for failure to follow fall interventions and care plans to maintain resident safety, and failure to protect a resident from verbal intimidation and abuse by staff. Two licensed practical nurses were terminated following the abuse investigation. The facility implemented corrective actions including staff education and monitoring.

The complaint investigation was substantiated with violations found related to failure to follow fall interventions, resident safety, abuse protection, and deficiencies in care and documentation.

The investigation found the facility in compliance with call notification, restraint, investigation submission, and noise control allegations. However, violations were found related to failure to follow fall interventions and maintain resident safety, failure to protect residents from abuse, and multiple deficiencies in care including inadequate bathing frequency, incomplete wound treatment administration, and incomplete medication and treatment documentation.

The complaint investigation included allegations that the facility failed to protect residents from residents with behaviors, maintain items essential for resident care, maintain an effective housekeeping program, resolve grievances timely, ensure staff training, prevent misappropriation of narcotic medications, protect residents from abuse, notify practitioners of change in condition, ensure MDS accuracy, submit investigations timely, provide care per physician orders, ensure dental services, implement fall interventions, maintain resident mobility, serve meals per Food Code, answer call lights promptly, and prevent misappropriation of narcotics. Several allegations were substantiated with deficiencies cited.

The facility was found deficient in multiple areas including resident rights, personal funds management, privacy, abuse prevention, misappropriation, staff training, dental services, fall prevention, nutrition, medication management, infection control, housekeeping, environment, and life safety code compliance. Several residents were affected by these deficiencies, and the facility failed to maintain correction for previously cited deficiencies.

The complaint alleged the facility failed to ensure residents do not elope. The investigation included observations, record reviews, and interviews with residents and staff. No violation was written for elopement, but a related tag was cited for failure to accommodate smoking/tobacco use preferences.

The facility failed to accommodate residents' needs and preferences for smoking or tobacco use upon admission, affecting four residents. The facility enforced a smoke-free campus policy without adequate accommodation, including confiscation of tobacco products and restricting residents from smoking on or off campus. Residents were offered smoking cessation programs and supervised outdoor tobacco use up to three times daily. The facility census was 135.

The December 1, 2015 survey found the facility was not in substantial compliance, with deficiencies constituting actual harm to resident health and safety but not immediate jeopardy. A civil money penalty was imposed due to these deficiencies, specifically related to pressure sores (F314).

The complaint alleged the facility failed to protect residents from injury. The allegation was investigated with no issues identified related to the allegation, but an unrelated deficiency was cited.

The investigation found no issues with meal service, care interventions, or resident interviews related to the allegation. However, an unrelated deficiency was cited regarding incomplete documentation of medication administration for one resident's wound care.

The complaint investigation was triggered by allegations that the facility failed to ensure prompt response to calls for assistance, failed to identify changes in condition, failed to ensure call lights were operational and in reach, and failed to provide care and services according to practitioner's orders. The investigation included observations, interviews with residents, family members, and staff, and record reviews. No deficiencies were found related to call lights or change in condition, but multiple deficiencies were found related to bathing care, wound care, staffing, communication with the medical director, and quality assurance processes.

The investigation found no deficiencies related to call light response, call light operation, or identification of change in condition. However, deficiencies were identified related to failure to provide bathing care as scheduled for 12 sampled residents, failure to provide treatment to prevent and promote healing of pressure ulcers for one resident, insufficient nursing staff to provide care including bathing, failure to notify the medical director of staffing and care issues, and failure of the quality assurance committee to implement corrective plans for bathing deficiencies identified in the prior annual survey.

The visit included a complaint investigation triggered by allegations including failure to maintain environment to prevent accidents, failure to provide care and treatment of indwelling catheters, insufficient staffing, failure to provide ordered tube feeding formula, dehydration prevention, pressure sore care, and protection from misappropriation. The facility was found in violation only for environmental safety related to unlocked chemical closets and unsafe equipment.

The facility was found deficient in multiple areas including environment safety, resident dignity and respect, staffing sufficiency, care and treatment, housekeeping and maintenance, medication administration, infection control, immunization documentation, diet management, medication storage, and life safety code compliance. Several deficiencies were repeat citations from previous surveys.

The complaint investigation was substantiated with findings of failure to treat residents with respect and dignity, failure to maintain essential equipment during power outages, failure to provide medications timely and per physician orders, and failure to maintain accurate medication administration procedures. Some allegations such as call light response and housekeeping were not substantiated.

The investigation substantiated several deficiencies including residents being transported with inadequate privacy coverings, delayed administration of pain and other medications, medication availability issues due to pharmacy supply problems, and electrical power failures in resident rooms caused by overloaded breakers. Some allegations such as call light response and housekeeping were found to have no issues. The facility was cited for multiple federal and state licensure violations related to dignity, medication administration, and electrical safety.

The complaint alleged the facility failed to follow care planned interventions to prevent injuries, failed to report significant injuries to regulatory authorities, and failed to notify family or responsible party of change in condition. The investigation included interviews, observations, and record reviews and substantiated these allegations with cited violations.

The investigation found violations related to failure to report significant injuries timely, failure to update care plans with current orders for transfers, failure to ensure call light accessibility for a resident, and failure to follow care planned interventions to prevent injuries. Specific deficiencies were cited under federal and state licensure tags F225, F280, and F282.

The complaint investigation included allegations that the facility failed to submit investigations within 5 working days, failed to administer medications according to practitioner's orders, failed to provide care to prevent incontinence, failed to protect residents from abuse, and failed to change fall interventions after residents were identified at risk for falls. The facility was substantiated for failure to submit investigations timely and failure to change fall interventions. Other allegations were not substantiated.

The investigation found the facility failed to submit investigations within 5 working days and failed to change fall interventions for one resident at high risk for falls. No violations were found related to medication administration, incontinence care, or resident abuse. The facility census was 117.

The complaint investigation substantiated allegations that the facility failed to ensure clean and groomed hair, skin, teeth, and/or nails; failed to ensure meals were attractive and palatable; failed to provide scheduled bathing opportunities; failed to provide sufficient nursing staff; and failed to reposition and toilet a dependent resident as ordered. No abuse violations were found. The facility was found deficient in multiple areas related to resident care and quality assurance.

The facility failed to ensure residents received baths as scheduled or per their choice, with multiple residents receiving fewer baths than scheduled. The facility also failed to provide adequate repositioning and toileting for a dependent resident, failed to maintain sufficient nursing staff to provide care, and failed to provide meals that were palatable and attractive. No abuse violations were found. The facility's Quality Assurance Committee failed to develop and implement plans of action to correct repeated deficiencies related to meal quality.

The complaint investigation included allegations of failure to provide care and treatment to promote wound healing, failure to report allegations of abuse, failure to identify and evaluate changes in condition, failure to ensure residents are not retaliated against, failure to ensure catheter care is performed as ordered, and failure to ensure privacy of residents' medical condition. The investigation found some substantiated deficiencies as detailed in the findings summary.

The investigation found no violation regarding wound healing, change in condition identification, retaliation, catheter care as ordered, or privacy. However, the facility failed to submit a completed investigation of alleged abuse within five working days, failed to provide bathing as requested for some residents, failed to prevent staff from obtaining vital signs while a resident was sleeping, failed to ensure call lights were within reach for some residents, failed to maintain a clean and odor-free environment, failed to accurately code oral/dental status in assessments, failed to develop comprehensive care plans addressing diuretic use and non-pharmacological interventions, failed to identify and assess causes of bruising and skin tears, failed to obtain medical reassessment for continued catheter use, failed to monitor electrolyte labs for a resident on diuretics, failed to justify antianxiety medication use, failed to obtain registered dietitian review for ongoing weight loss, failed to maintain food temperatures and consistency, failed to ensure clean cooking utensils and proper hand hygiene, failed to identify and correct medication label discrepancies, failed to sanitize and store nebulizer equipment properly, failed to ensure handwashing during dressing changes, failed to maintain an effective pest control program, failed to complete pain admission assessments, and failed to document medication administration properly.

The complaint investigation included allegations that the facility failed to provide care and treatment according to standards for PICC lines, failed to prevent pressure sores, and failed to provide appropriate catheter care. The investigation involved medical record reviews, observations, and interviews with staff and residents. The facility was found compliant with PICC line care but deficient in pressure sore assessment and catheter care.

The facility was found to have no violation regarding PICC line care. However, it failed to accurately assess and document pressure sores for one resident, and failed to provide appropriate catheter care by licensed nurses, resulting in urinary tract infections. Documentation errors and inadequate wound assessments were also identified.

The complaint investigation included allegations that the facility failed to investigate injuries of unknown origin, failed to protect residents from abuse, failed to investigate and report allegations of abuse, failed to notify practitioners of care plan changes, failed to maintain a pest-free environment, failed to ensure residents were dressed appropriately, and failed to provide appropriate calorie intake. The investigation found substantiated deficiencies related to failure to investigate and monitor bruising and pest control, but no violations related to abuse or care plan notification.

The facility was found deficient in investigating and monitoring bruising of unknown origin on one resident (Resident 3), with bruises not routinely monitored or documented. The facility failed to investigate the causal factors of bruising and did not have policies or routine monitoring for bruises. Additionally, the facility failed to maintain an effective pest control program as ants were found in multiple resident rooms despite ongoing treatments. No violations were found related to abuse, reporting abuse, notification of care plan changes, resident clothing, or calorie intake.

The facility failed to revise resident care plans to reflect updated safety needs and transfer methods for sampled residents, failed to ensure call lights were within reach for a resident, and failed to identify and document safety risks and incidents when a resident exited the building unattended. The facility did not document incidents of elopement or reassess safety risks as required.

The facility was found deficient in multiple areas including failure to immediately report suspected misappropriation of narcotics, inadequate housekeeping and maintenance, incomplete care plans for blood sugar testing and insulin injections, improper narcotic inventory management, infection control lapses, inadequate bathroom ventilation, incomplete clinical records for oxygen therapy, failure to maintain quality assurance program, and life safety code violations including exit door force requirements, sprinkler obstructions, and improper electrical wiring.

The facility was found deficient in housekeeping and maintenance services due to damaged hallway carpeting posing a hazard to residents, failure to complete a significant change Minimum Data Set (MDS) assessment for a resident with declining condition, failure to serve menu items as planned for residents on dementia units, and failure to maintain an effective pest control program due to ant infestation in a resident's room.

The facility was found deficient in multiple areas including housekeeping and maintenance services, failure to update resident care plans, medication record keeping and storage, infection control practices, follow-up assessments after falls, and multiple life safety code violations such as smoke door maintenance, exit access obstructions, sprinkler system coverage, electrical safety, and storage of combustibles in oxygen storage areas.

The complaint investigation focused on infection control practices related to catheter care and the facility's infection control program's failure to investigate infections properly. The complaint was substantiated based on observations and record reviews.

The facility failed to ensure proper hand hygiene and glove changing during catheter care for Residents 2 and 3, and the infection control program did not adequately investigate an infection for Resident 2. Observations and record reviews confirmed these deficiencies, including improper catheter care technique and incomplete infection tracking.

The facility was found deficient in multiple areas including failure to develop an initial care plan within 24 hours of admission, failure to notify physicians of significant changes such as stage II pressure ulcers and ineffective medications, failure to update care plans with increased monitoring interventions for behaviors, failure to provide timely services for a self-abusive resident, and failure to prevent the development of pressure ulcers in an at-risk resident.

The complaint investigation revealed that the facility failed to submit a thorough investigation into a significant injury sustained by Resident 3 and failed to complete an assessment related to unusual symptoms for Resident 4. The investigation lacked interviews with direct care staff and licensed nurses, and the symptoms were not assessed or documented as required.

The facility failed to conduct a thorough investigation into a significant injury sustained by Resident 3, including lack of interviews with direct care staff, and failed to assess and document unusual symptoms for Resident 4. The investigation and documentation deficiencies were confirmed by interviews with staff and review of medical records.

The facility was found deficient in multiple areas including failure to notify physicians of resident condition changes, inadequate room temperature control, incomplete care plans for medication monitoring, inappropriate catheter use without medical justification, improper oxygen administration, significant medication errors, food service sanitation issues, incomplete medication orders, and multiple life safety code violations including faulty smoke doors, obstructed sprinkler heads, and unsafe electrical wiring.

Deficiencies included failure to properly document medications not given, inadequate evaluation and recording of wounds, failure to develop a preliminary nursing care plan within 24 hours of admission, and failure to maintain accurate resident inventory records. The facility acknowledged these issues and outlined corrective actions and monitoring plans.