Springs at Monarch Landing, The

In the surveyor’s words

From the most serious findings on record at Springs at Monarch Landing, The, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 9, 2026

  Based on observation, interview, and record review, the facility failed to supervise a high-risk fall resident (R1) and provide a safe environment to a dependent resident (R2) when rendering care.These failures resulted in R1 having an unwitnessed fall and sustaining a laceration to her right posterior scalp requiring sutures, and in R2 having a witnessed fall and sustaining a fracture to her left ninth rib. This applies to 2 out of 3 (R1 and R2) reviewed for falls.The findings include:1. The EMR (Electronic Medical Record) said R1 had multiple diagnoses, including a history of falls, dementia with anxiety disorder, muscle weakness, osteoporosis, and osteoarthritis. R1's MDS (Minimum Data Set) dated 4/21/2026, said she had moderate cognitive impairment and had limited memory recall. […]

• No harm, potential for more than minimal, widespreadF812Jul 31, 2024

  Based on observation, interview and record review, the facility failed to sanitize pots and pans per facility policy. This applies to all 81 residents receiving oral diets in the facility. The findings include: Long term Care Facility Application for Medicare and Medicaid, dated July 28, 2024, shows the facility census was 82. Diet Type Report dated July 28,2024, shows one resident did not receive an oral diet at the facility. On July 28, 2024, at 10:18 AM with V6 (Food Service Manager), the dish machine sanitizer temperature was measured using a 180 degree F (Fahrenheit) test strip. The test strip instructions showed the black indicator line on the test strip was to turn completely orange when 180 degrees F was reached during the sanitizing cycle of the dish machine. […]

• No harm, potential for more than minimal, widespreadF803Sep 8, 2022

  Based on observation, interview, and record review the facility failed to ensure residents were served menu items from the dietitian approved spreadsheet to meet the resident's nutritional needs. This applies to all 74 residents residing in the facility. The findings include: The Resident Census and Condition Report (Federal Form 672) shows that on 9/6/22, the facility housed 74 residents. The Spreadsheet for Tuesday's lunch includes tilapia, bowtie pasta, kale salad and pear halves for the resident's on a general diet. The Spreadsheet shows pureed tilapia, bowtie pasta, green beans and pears for the resident's on a pureed diet. On 9/6/22 at 10:31 AM, V6 (Cook) pureed the noon meal. V6 pureed fish and green beans. […]

• No harm, potential for more than minimal, widespreadF812Sep 8, 2022

  Based on observation, interview, and record review the facility failed to ensure food was stored and served in a sanitary manner, dishes were cleaned under sanitary conditions, and food temperatures were taken to prevent foodborne illnesses for all 74 residents residing in the facility. The findings include: The Resident Census and Condition Report (Federal Form 672) shows that on 9/6/22, the facility housed 74 residents. 1. On 9/6/22 at 10:15 AM, there were multiple opened food items in the dry storage area that were not dated with the date opened. These food items include: baking powder, lime gelatin, marshmallows, noodles, strawberry gelatin, brown sugar, 2 bags of pecans and sunflower kernels. A bag of pecans and a box of sunflower kernels were not sealed closed. […]

• No harm, potential for more than minimal, widespreadF880Sep 8, 2022

  Based on observation, interview, and record review the facility failed to socially distance residents who are on droplet isolation while in the dining room. This applies to two residents (R19, R21) outside the sample reviewed for infection control. This has the potential to affect all 74 residents in the facility. The findings include: The facility face sheet for R19 shows diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility face sheet for R21 shows diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessment dated [DATE] shows her to be cognitively intact. On 9/6/2022 at the noon meal, R19 was observed sitting next to another resident at a table in the dining room. The two residents were not sitting six feet away from each other. […]