Care Citations

MSM Brigham City LLC

1010 South Medical Drive, Brigham City, UT, 84302 · 4353105800

On the CMS record

Overall rating (CMS)
3 / 5
Health inspection rating
2 / 5
Staffing rating
4 / 5
Certified beds
41
Ownership type
For profit - Limited Liability company
Chain
MISSION HEALTH SERVICES

Inspection findings on record (47)

Quoted exactly as CMS published them. We do not rewrite findings.

— Quality of Life and Care Deficiencies

Tag 0690 · scope/severity G · actual harm

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Administration Deficiencies

Tag 0775 · scope/severity E · potential for more than minimal harm

Keep complete, dated laboratory records in the resident's record.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0801 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0804 · scope/severity E · potential for more than minimal harm

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity E · potential for more than minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity D · potential for more than minimal harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0628 · scope/severity D · potential for more than minimal harm

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity D · potential for more than minimal harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0755 · scope/severity D · potential for more than minimal harm

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Recorded as corrected on .

— Administration Deficiencies

Tag 0773 · scope/severity D · potential for more than minimal harm

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Recorded as corrected on .

— Administration Deficiencies

Tag 0779 · scope/severity D · potential for more than minimal harm

Keep signed and dated reports of x-rays and other diagnostic services in the residents record.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0600 · scope/severity G · actual harm

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity E · potential for more than minimal harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity E · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity E · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0554 · scope/severity D · potential for more than minimal harm

Allow residents to self-administer drugs if determined clinically appropriate.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0610 · scope/severity D · potential for more than minimal harm

Respond appropriately to all alleged violations.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity D · potential for more than minimal harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0755 · scope/severity D · potential for more than minimal harm

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0756 · scope/severity D · potential for more than minimal harm

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0757 · scope/severity D · potential for more than minimal harm

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Recorded as corrected on .

— Administration Deficiencies

Tag 0770 · scope/severity D · potential for more than minimal harm

Provide timely, quality laboratory services/tests to meet the needs of residents.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0881 · scope/severity D · potential for more than minimal harm

Implement a program that monitors antibiotic use.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity L · immediate jeopardy

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0600 · scope/severity J · immediate jeopardy

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0603 · scope/severity G · actual harm

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0585 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0607 · scope/severity E · potential for more than minimal harm

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0759 · scope/severity E · potential for more than minimal harm

Ensure medication error rates are not 5 percent or greater.

Recorded as corrected on .

— Administration Deficiencies

Tag 0835 · scope/severity E · potential for more than minimal harm

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Recorded as corrected on .

— Administration Deficiencies

Tag 0867 · scope/severity E · potential for more than minimal harm

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0888 · scope/severity E · potential for more than minimal harm

Ensure staff are vaccinated for COVID-19

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0554 · scope/severity D · potential for more than minimal harm

Allow residents to self-administer drugs if determined clinically appropriate.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0561 · scope/severity D · potential for more than minimal harm

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity D · potential for more than minimal harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0583 · scope/severity D · potential for more than minimal harm

Keep residents' personal and medical records private and confidential.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0609 · scope/severity D · potential for more than minimal harm

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0610 · scope/severity D · potential for more than minimal harm

Respond appropriately to all alleged violations.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0622 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity D · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0729 · scope/severity D · potential for more than minimal harm

Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0745 · scope/severity D · potential for more than minimal harm

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0825 · scope/severity D · potential for more than minimal harm

Provide or get specialized rehabilitative services as required for a resident.

Recorded as corrected on .

Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 465165