Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
1% better than Utah average
Utah average: 7.9 deficiencies/year
Deficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 12, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to report alleged abuse or neglect, failure to provide appropriate treatment and care, and failure to ensure a safe environment to prevent accidents for residents at the facility.
Complaint Details
The investigation found that the facility failed to report two instances of potential neglect related to serious bodily injury to the State Survey Agency. Resident 7 was injured during transport without proper seatbelt use, and Resident 4 fell reaching for a call light, resulting in a hip fracture. The facility did not report these incidents as required.
Findings
The facility failed to report two instances of potential neglect involving serious bodily injury to the State Survey Agency. Resident 7 was transported without proper seatbelt use and sustained bilateral femur fractures. Resident 4 fell reaching for a call light that had dropped, resulting in a hip fracture. The facility also failed to implement hospital discharge orders for daily weights for Resident 1 in a timely manner.
Deficiencies (3)
F 0609: The facility did not ensure timely reporting of suspected abuse, neglect, or theft to proper authorities for two residents with serious bodily injuries.
F 0684: The facility failed to provide treatment and care according to orders and resident preferences, delaying daily weights for a resident with heart failure by 6 days after admission.
F 0689: The facility did not ensure a safe environment and adequate supervision to prevent accidents, resulting in a resident transported without proper seatbelt use sustaining bilateral femur fractures and another resident falling and fracturing his hip.
Report Facts
Weights missing: 7
BIMS score: 15
BIMS score: 10
BIMS score: 9
Pain rating: 4
Pain rating: 6
Pain rating: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Nurse Consultant | Regional Nurse Consultant (RNC) | Interviewed regarding transport incident and best practice for securing residents. |
| Previous Director of Nursing | Previous Director of Nursing (PDON) | Interviewed regarding incident reporting and resident transport. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding daily weights order 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 fall risk and call light checks for Resident 4. |
| Licensed Practical Nurse 1 | Licensed Practical Nurse (LPN) 1 | Interviewed regarding fall risk and call light checks for Resident 4. |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Nov 16, 2023
Visit Reason
The inspection was conducted following complaints regarding resident rights, diet changes without proper notification, unresolved grievances, food quality, restorative nursing services, psychotropic medication monitoring, and Minimum Data Set (MDS) data transmission issues.
Complaint Details
The complaint investigation focused on resident rights violations, diet changes without proper notification, unresolved grievances especially about food quality, failure to provide restorative nursing services, failure to transmit MDS data timely, and inadequate monitoring of psychotropic medications.
Findings
The facility failed to inform a resident about a diet change, did not resolve multiple resident grievances especially about food quality, did not provide ordered restorative nursing services, failed to transmit MDS data timely, and did not adequately monitor psychotropic medication use. Food served was frequently reported as unpalatable and improperly prepared.
Deficiencies (8)
F 0552: The facility did not inform resident 68 in understandable language about the change in diet from regular to renal, affecting his ability to choose his preferred diet.
F 0561: The facility did not promote resident self-determination by restricting resident 68's ability to choose his diet due to a new policy removing risk vs. benefit diet choice forms.
F 0565: The facility failed to consider and act promptly on grievances filed by residents and resident council concerning issues of resident care and life in the facility.
F 0584: The facility did not provide a safe, clean, comfortable, and homelike environment by prohibiting resident 68 from having a personal mini refrigerator to store food, despite his nutritional needs and prior use.
F 0640: The facility failed to transmit Minimum Data Set (MDS) assessment data for multiple residents within 7 days of completion as required.
F 0688: The facility did not provide appropriate care to maintain or improve range of motion and mobility for residents with limited mobility, including failure to provide ordered hand splints and restorative nursing services.
F 0758: The facility did not ensure that psychotropic medications were given only when necessary with adequate monitoring, as resident 18 received psychotropic drugs daily without behavior monitoring.
F 0804: The facility did not provide food that was palatable, attractive, and at a safe temperature, with multiple residents complaining about food quality and unresolved grievances related to food.
Report Facts
Residents sampled: 40
Residents affected by MDS transmission failure: 7
Psychotropic medication orders: 3
Residents complaining about food: 13
Grievances about food with no resolution: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RD 1 | Registered Dietitian | Involved in diet change discussions and resident education |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding diet changes and psychotropic medication monitoring |
| RN 1 | Registered Nurse | Responsible for applying hand splints to resident 22 |
| Minimum Data Set Coordinator | MDS Coordinator | Confirmed untransmitted MDS assessments and restorative nursing program status |
| Activities Director | Activities Director | Interviewed about grievance process and food complaints |
| Social Worker | Facility Social Worker | Involved in grievance resolution process |
| Administrator | Facility Administrator | Interviewed about fridge policy and grievance process |
Inspection Report
Routine
Census: 40
Deficiencies: 8
Date: Nov 16, 2023
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements for nursing home care and resident rights.
Findings
The facility was found deficient in multiple areas including failure to inform a resident about diet changes, unresolved resident grievances especially regarding food quality, failure to provide restorative nursing services, inadequate monitoring of psychotropic medication, and poor food quality and palatability.
Deficiencies (8)
F 0552: The facility did not inform resident 68 in understandable language about changes in diet orders, including risks, benefits, and alternatives.
F 0561: The facility failed to promote resident self-determination by not informing resident 68 of diet changes and restricting resident choice due to new company policy.
F 0565: The facility did not consider or act promptly on grievances filed by residents and resident council, with multiple unresolved grievances documented.
F 0584: The facility did not provide a safe, clean, comfortable environment by prohibiting resident 68 from having a personal mini refrigerator to store food, citing fire hazard concerns.
F 0640: The facility failed to transmit Minimum Data Set (MDS) assessments for multiple residents within 7 days of completion as required.
F 0688: The facility did not ensure residents with limited mobility received appropriate restorative nursing services and ordered devices, including failure to apply hand splints and provide range of motion exercises.
F 0758: The facility did not ensure psychotropic medications were given only when necessary with adequate monitoring; resident 18 received psychotropic drugs daily without behavior monitoring.
F 0804: The facility failed to provide food that was palatable, attractive, and at a safe temperature; multiple residents complained about food quality, and grievances about food were unresolved.
Report Facts
Residents sampled: 40
Residents affected by diet notification deficiency: 1
Residents affected by grievance follow-up deficiency: 4
Residents affected by MDS transmission deficiency: 7
Residents affected by restorative nursing deficiency: 3
Residents affected by psychotropic medication monitoring deficiency: 1
Residents affected by food quality complaints: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RD 1 | Registered Dietitian | Discussed diet changes and new company diet policy affecting resident 68 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding diet changes and psychotropic medication monitoring |
| RN 1 | Registered Nurse | Responsible for applying hand splints to resident 22 |
| Minimum Data Set Coordinator | MDS Coordinator | Confirmed untransmitted MDS assessments and restorative nursing program status |
| Activities Director | Activities Director | Discussed resident grievances and snack portion complaints |
| Social Worker | Facility Social Worker | Discussed grievance resolution process |
| Administrator | Facility Administrator | Discussed fridge policy and grievance process |
Inspection Report
Deficiencies: 0
Date: Nov 17, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Monument Healthcare Taylorsville, representing a regulatory inspection visit.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 12
Date: Sep 12, 2019
Visit Reason
Routine inspection of Monument Healthcare Taylorsville nursing home to assess compliance with regulatory requirements including resident care, medication management, nutrition, and safety.
Findings
The facility was found deficient in multiple areas including failure to provide requested liquids to a resident, incomplete care plans for fall prevention, inadequate assistance with activities of daily living including feeding, failure to maintain accurate medication and narcotic records, failure to follow physician orders for catheter changes, delayed implementation of dietary interventions for significant weight loss, and failure to monitor psychotropic medication side effects.
Deficiencies (12)
F 0561: The facility failed to honor a resident's right to self-determination by not providing requested thin liquids and water despite a signed risk versus benefit form.
F 0656: The facility did not develop and implement comprehensive care plans with measurable objectives and timely interventions for residents with multiple falls.
F 0677: The facility failed to provide necessary assistance with activities of daily living including feeding for residents unable to perform these tasks independently.
F 0689: The facility failed to ensure a safe environment and adequate supervision to prevent falls, resulting in multiple falls and injuries for several residents.
F 0690: The facility failed to follow physician orders for catheter changes and used incorrect catheter sizes, resulting in complications and hospital admission.
F 0692: The facility failed to maintain adequate nutritional status for a resident with significant weight loss and did not provide timely dietary interventions or assistance with eating.
F 0755: The facility failed to maintain accurate records of controlled drug administration, with multiple discrepancies between narcotic logs and medication administration records.
F 0756: The facility did not perform timely monthly drug regimen reviews and failed to act on pharmacist recommendations for monitoring and medication adjustments.
F 0757: The facility failed to monitor psychotropic medication side effects and did not implement recommended assessments for extrapyramidal symptoms.
F 0761: The facility failed to ensure safe and secure storage of medications and biologicals, including unlabeled medications, expired enteral feedings, and unlocked treatment carts containing medications.
F 0802: The facility did not employ sufficient dietary support personnel to serve meals on time and assist residents with feeding, resulting in delayed meal service and inadequate feeding assistance.
F 0842: The facility failed to maintain accurate resident medical records, including discrepancies between medication administration records and narcotic logs, and inaccurate documentation of catheter changes.
Report Facts
Weight loss: 20
Medication discrepancies: 101
Medication discrepancies: 14
Medication discrepancies: 2
Meal service delay: 25
Meal service delay: 23
Meal service delay: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Documented catheter change that was not performed on resident 18. |
| RN 1 | Registered Nurse | Interviewed about narcotic administration and fall interventions. |
| DON | Director of Nursing | Interviewed about multiple deficiencies including medication monitoring, catheter orders, and fall prevention. |
| CNA 3 | Certified Nursing Assistant | Observed and interviewed regarding feeding assistance and resident care. |
| RN 2 | Registered Nurse | Interviewed about resident 46's extrapyramidal symptoms. |
| LPN 2 | Licensed Practical Nurse | Interviewed about catheter care and wound treatment cart. |
Viewing
Loading inspection reports...
