A list of the most recent deficiencies for Msm Brigham City LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-12-12 | 2024-02-07 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-12-12 | 2024-01-31 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-12-18 | 2024-01-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-18 | 2024-01-18 | N |
| Respond appropriately to all alleged violations. | Health | 2023-12-18 | 2024-01-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-18 | 2024-01-18 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-12-18 | 2024-01-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-12-18 | 2024-01-18 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-12-18 | 2024-01-18 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-12-18 | 2024-01-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-18 | 2024-01-18 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-12-18 | 2024-01-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-18 | 2024-01-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-18 | 2024-01-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-18 | 2024-01-18 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-12 | 2023-12-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-12 | 2023-12-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-12-12 | 2023-12-12 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-03-02 | 2022-04-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-03-02 | 2022-04-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-02 | 2022-04-15 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-03-02 | 2022-04-15 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-03-02 | 2022-04-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-02 | 2022-04-15 | N |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2022-03-02 | 2022-04-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-02 | 2022-04-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-02 | 2022-04-15 | N |
| Respond appropriately to all alleged violations. | Health | 2022-03-02 | 2022-04-15 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-03-02 | 2022-04-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-02 | 2022-04-15 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-03-02 | 2022-04-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-02 | 2022-04-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-02 | 2022-04-15 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-03-02 | 2022-04-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-03-02 | 2022-04-15 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-02 | 2022-04-15 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2022-03-02 | 2022-04-15 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-03-02 | 2022-04-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-02 | 2022-04-15 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-03-01 | 2022-03-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-03-01 | 2022-03-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-08 | 2021-11-24 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-27 | 2020-02-26 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2020-01-27 | 2020-02-26 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-01-27 | 2020-02-26 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2020-01-27 | 2020-02-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-27 | 2020-02-26 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-01-27 | 2020-02-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-28 | 2020-01-29 | N |
