Deficiencies (last 4 years)
Deficiencies (over 4 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
11% better than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 12, 2024
Visit Reason
The inspection was conducted due to complaints and incidents involving alleged neglect and failure to report injuries and abuse in a nursing home setting, specifically concerning two residents who sustained serious injuries.
Complaint Details
The complaint investigation focused on two residents (Resident 4 and Resident 7) who sustained serious bodily injuries. Resident 7 was injured during transport to dialysis when not properly secured with a seatbelt, resulting in bilateral femur fractures. Resident 4 fell while reaching for a call light that had fallen to the floor, resulting in a hip fracture. The facility failed to report these incidents to the State Survey Agency and Adult Protective Services within required timeframes.
Findings
The facility failed to timely report alleged violations involving abuse and neglect to the State Survey Agency and Adult Protective Services. Two residents sustained serious injuries due to inadequate supervision and failure to follow safety protocols, including improper securing of a resident during transport and failure to ensure a resident's call light was within reach, resulting in falls and fractures.
Deficiencies (3)
Failure to timely report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property.
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, specifically failure to implement daily weights for a resident with heart failure until 6 days after admission.
Failure to ensure the resident environment remains free from accident hazards and provide adequate supervision to prevent accidents, resulting in fractures from a fall during transport and a fall from bed due to call light being out of reach.
Report Facts
Deficiencies cited: 3
Resident 1 missing weights: 7
Resident 4 BIMS score: 10
Resident 7 BIMS score: 15
Incident dates: Dec 29, 2023
Incident dates: Feb 9, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Nurse Consultant | Regional Nurse Consultant (RNC) | Interviewed regarding incident involving Resident 7 and transport safety. |
| Previous Director of Nursing | Previous Director of Nursing (PDON) | Interviewed regarding incident involving Resident 7 and failure to report. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding failure to implement daily weights and fall prevention. |
| Van Driver | Van Driver (VD) | Interviewed regarding transport incident involving Resident 7. |
| Registered Nurse 2 | Registered Nurse (RN) 2 | Nurse on duty during Resident 4's fall. |
| Certified Nursing Assistant 1 | Certified Nursing Assistant (CNA) 1 | Interviewed regarding Resident 4's care and fall prevention. |
| Licensed Practical Nurse 1 | Licensed Practical Nurse (LPN) 1 | Interviewed regarding Resident 4's fall risk and care. |
Inspection Report
Routine
Deficiencies: 7
Date: Nov 16, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, including diet management, resident rights, grievance handling, restorative nursing services, psychotropic medication use, and food quality.
Findings
The facility failed to inform a resident about a diet change, did not allow a resident to have a personal mini fridge despite prior approval, did not follow up on resident grievances especially related to food quality, failed to transmit Minimum Data Set (MDS) assessments timely, did not provide restorative nursing services as required, failed to ensure appropriate use of psychotropic medication monitoring, and served food that was frequently unpalatable, cold, or improperly prepared.
Deficiencies (7)
Facility did not inform resident 68 of a diet change from regular to renal diet and did not allow resident to choose diet due to new company policy.
Facility did not allow resident 68 to have a personal mini refrigerator to store food despite prior use and requests, citing fire hazard policy.
Facility did not consider or act promptly on grievances filed by residents, including multiple unresolved grievances about food quality.
Facility failed to transmit Minimum Data Set (MDS) assessments for multiple residents within 7 days of completion.
Facility did not provide restorative nursing services (RNA) to residents with limited mobility and failed to provide ordered splints for contracture management.
Facility did not ensure psychotropic medication monitoring for resident 18 receiving multiple psychotropic drugs.
Facility did not provide food that was palatable, attractive, or at a safe temperature; multiple residents complained and grievances were unresolved; test tray was unpalatable and cold.
Report Facts
Residents sampled: 40
Residents affected by diet change deficiency: 1
Residents affected by grievance deficiency: 5
Residents with untransmitted MDS: 7
Residents affected by restorative nursing deficiency: 3
Residents affected by psychotropic medication deficiency: 1
Residents affected by food quality deficiency: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RD 1 | Registered Dietitian | Involved in diet change and resident education for resident 68 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding diet change and psychotropic medication monitoring |
| Activities Director | Activities Director (AD) | Interviewed regarding grievances and food complaints |
| Social Worker | Facility Social Worker (SW) | Interviewed regarding grievance process |
| Administrator | Facility Administrator (ADM) | Interviewed regarding fridge policy and grievance process |
| Minimum Data Set Coordinator | MDS Coordinator (MDSC) | Interviewed regarding untransmitted MDS assessments and restorative nursing program |
| RN 1 | Registered Nurse | Interviewed regarding splint application for resident 22 |
| CNA 1 | Certified Nursing Assistant | Interviewed regarding meal checks and restorative nursing assistant training |
| CNA 2 | Certified Nursing Assistant | Interviewed regarding restorative nursing assistant duties |
Inspection Report
Routine
Deficiencies: 8
Date: Nov 16, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, including diet management, resident rights, grievance handling, restorative nursing services, psychotropic medication use, and food quality.
Findings
The facility failed to inform a resident about a diet change, did not allow a resident to have a personal mini fridge, did not follow up on resident grievances, failed to provide restorative nursing services, did not monitor psychotropic medication use adequately, and served food that was frequently unpalatable and served at unsafe temperatures.
Deficiencies (8)
Facility did not inform resident 68 in language that could be understood about the change in their diet order.
Facility did not promote and facilitate resident self-determination through support of resident choice, specifically resident 68 was not aware of diet change.
Facility did not allow resident 68 to have a personal mini refrigerator to store food, citing fire hazard concerns.
Facility did not consider views of resident or family groups and did not act promptly on grievances, with multiple unresolved grievances related to food and resident-staff interactions.
Facility failed to transmit Minimum Data Set (MDS) assessments for multiple residents within 7 days of completion.
Facility did not ensure residents with limited mobility received appropriate services and assistance to maintain or improve mobility; resident 22 did not have ordered hand splints applied and residents did not receive restorative nursing assistant (RNA) services.
Facility did not ensure psychotropic medication was given only when necessary with adequate behavior monitoring; resident 18 received psychotropic drugs daily without behavior monitoring.
Facility did not provide food prepared by methods that conserve nutritive value, flavor, and appearance or palatable, attractive, and at a safe temperature; multiple residents complained about food quality and temperature, and grievances were unresolved.
Report Facts
Residents sampled: 40
Residents affected by diet communication deficiency: 1
Residents affected by grievance follow-up deficiency: 5
Residents with untransmitted MDS: 7
Residents affected by restorative nursing deficiency: 3
Residents affected by psychotropic medication monitoring deficiency: 1
Residents affected by food quality deficiency: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RD 1 | Registered Dietitian | Involved in diet change and education for resident 68 |
| DON | Director of Nursing | Provided information about diet change and fridge policy |
| AD | Activities Director | Discussed grievances and snack complaints |
| SW | Social Worker | Grievance officer involved in grievance process |
| ADM | Administrator | Discussed fridge policy and grievance process |
| MDSC | Minimum Data Set Coordinator | Confirmed untransmitted MDS assessments and restorative nursing program status |
| RN 1 | Registered Nurse | Responsible for applying hand splints to resident 22 |
| CNA 1 | Certified Nursing Assistant | Reported double checking meals and food errors |
| CNA 2 | Certified Nursing Assistant | Trained as RNA but not scheduled for RNA duties |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 17, 2021
Visit Reason
The inspection was conducted as an annual survey of Monument Healthcare Taylorsville to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 10
Date: Sep 12, 2019
Visit Reason
The inspection was a routine survey of Monument Healthcare Taylorsville to assess compliance with regulatory requirements related to resident care, safety, medication management, and facility operations.
Findings
The survey identified multiple deficiencies including failure to honor resident choice regarding liquids, incomplete and untimely care plan updates especially related to falls and nutritional needs, inadequate assistance with feeding, unsafe medication management including narcotic administration discrepancies, failure to follow physician orders for catheter care, and lack of proper monitoring of psychotropic medication side effects.
Deficiencies (10)
Failure to honor resident 46's right to self-determination and choice regarding liquids, resulting in minimal harm or potential for actual harm.
Failure to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for residents 3 and 41, including after falls and other assessments.
Failure to provide necessary assistance with activities of daily living, including feeding, for residents 30, 41, and 46.
Failure to ensure a safe environment and adequate supervision to prevent accidents, resulting in multiple falls and injuries for residents 3, 30, and 41.
Failure to provide appropriate care and follow physician orders for catheter care for resident 18, including failure to change catheter as ordered.
Failure to provide adequate nutrition and timely interventions for significant weight loss for resident 41, including lack of assistance with eating.
Failure to maintain accurate medication records and reconcile narcotic administration with narcotic logs for resident 50.
Failure to ensure safe and secure storage of drugs and biologicals, including unlabeled medications, expired enteral feedings, and unlocked treatment cart.
Failure to act upon pharmacy recommendations in a timely manner for resident 46, including monitoring for involuntary movements and adjusting psychotropic medications.
Failure to monitor psychotropic medication side effects and indications for use for resident 46, including lack of assessments for extrapyramidal symptoms.
Report Facts
Weight loss: 20
Fall call light duration: 11
Fall call light duration: 8
Fall call light duration: 3
Fall call light duration: 4
Fall call light duration: 10
Weight loss percentage: 13.79
Weight measurements: 144.8
Weight measurements: 147
Weight measurements: 142.6
Weight measurements: 138.8
Weight measurements: 136
Weight measurements: 131
Weight measurements: 131.2
Weight measurements: 129
Weight measurements: 124
Weight measurements: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MD 1 | Physician | Provided medical opinion on resident 3's psychiatric condition and fall risk |
| RN 1 | Registered Nurse | Interviewed regarding fall interventions and narcotic administration |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including fall interventions, medication monitoring, and catheter care |
| CNA 1 | Certified Nursing Assistant | Observed assisting residents and interviewed about feeding assistance |
| CNA 2 | Certified Nursing Assistant | Interviewed about feeding assistance and catheter care |
| CNA 3 | Certified Nursing Assistant | Interviewed about feeding assistance and fall prevention |
| CNA 5 | Certified Nursing Assistant | Interviewed about resident 46's feeding and behavioral issues |
| CNA 6 | Certified Nursing Assistant | Interviewed about fall interventions and resident care |
| CNA 7 | Certified Nursing Assistant | Interviewed about fall interventions and resident care |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding catheter care and medication administration |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding catheter care and wound treatment cart |
| LPN 3 | Licensed Practical Nurse | Documented catheter change and notified nurse practitioner |
| RN 2 | Registered Nurse | Interviewed about resident 46's extrapyramidal symptoms |
| RN 3 | Registered Nurse | Interviewed about wound treatment cart and medication administration |
| Physical Therapist | Physical Therapist | Interviewed about fall prevention interventions for resident 3 |
| Registered Dietitian | Registered Dietitian | Interviewed about nutritional monitoring and interventions for resident 41 |
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