Monarch Springs Wellness & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Monarch Springs Wellness & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF678Jul 13, 2023

  Based on observation, interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), would be provided if such care was needed per the resident's choice, and would only be provided to a resident subject to related physician orders and resident choice. The facility failed to have a system to ensure resident code statuses are obtained, ensure code status matched the resident's wishes, and ensure code statuses were accurately documented. The facility failed to obtain an ordered code status for 2 residents and failed to have congruently documented code status for 2 residents, out of 37 residents investigated for advanced directives. One resident had an order for full code, but a face sheet indicated do not resuscitate (DNR). […]

• Immediate jeopardy, isolatedF600Jun 5, 2023

  Based on interview and record review, the facility failed to ensure one resident was free from physical and verbal abuse and involuntary confinement (Resident #1). On 5/14/23 between 1:00 P.M. and 1:30 P.M., during lunch in the dining room, Certified Nursing Assistant (CNA) CNA A was observed by the Dietary Supervisor (DS), Dietary Aide (DA) B and Residents #3, #6, #2, #5 and #4 either hitting the resident in the head, raising his/her arms to the resident, yelling/cursing at the resident, and/or forcefully grabbing the resident's wheelchair to prevent the resident from exiting the dining room to go to his/her room and lay down. The DS and DA B failed to immediately intervene by separating the resident from the CNA and reporting what they witnessed to Nurse C. […]

• Actual harm, isolatedF689Jan 31, 2025

  Based on interview and record review, the facility failed to provide care and services to ensure one resident (Resident #1) was free from accident hazards when a Certified Nurse Aide (CNA) failed to secure the resident in bed before leaving to answer the call of another resident in a different room. The resident rolled of the bed and hit his/her head on the floor. The resident suffered two lacerations to the top of his/her head. The sample was four. The census was 44. The Administrator was notified on 1/31/25 at 2:53 P.M., of the past non-compliance, which occurred on 1/16/25. The facility provided training and in-servicing for all staff regarding the facility's resident safety policy. […]

• Actual harm, isolatedF686Oct 12, 2021

  Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice when the facility failed to assess wounds, document changes to the wound and/or notify the physician of the wound changes. This resulted in a delay in identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound was identified as moisture associated skin damage (MASD, a skin condition causing irritation and redness of the skin due to constant contact with a source of moisture) upon admission and was identified as a Stage IV pressure ulcer (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. […]

• No harm, potential for more than minimal, widespreadF812Jul 12, 2024

  Based on observations, interviews, document review, and facility policy review, the facility failed to ensure cleanliness and ensure food stored in one of one kitchen and in the unit nourishment room, was labeled, dated, and not expired. The failure had the potential to increase the prevalence and spread of foodborne illness and infection for 49 census residents. Findings include: Review of the facility's undated job description titled, Dietary Manager indicated it was the responsibility of DM to ensure compliance with regulatory standards during food preparation, storage, and service. […]