Monument Healthcare American Fork

Inspectors wroteBased on interview and record review, it was determined the facility did not ensure that residents who use psychotropic drugs received a gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically for 1 out of 19 sampled residents, a resident did not have an attempted GDR for psychotropic medications. Resident identifier: 20.

Inspectors wroteBased on observation, interview, and record review, it was determined that for 1 of 19 sampled residents, that the facility did not ensure that a resident was given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including eating. Specifically, a resident did not receive assistance with eating his meals. Resident Identifier: 1 Resident 1 was initially admitted [DATE], readmitted [DATE] with diagnoses including legal blindness, cerebral infarction, tremor, need for assistance with personal care, dysphagia following cerebral infarction, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Resident 1's medical record was reviewed from 9/2/25 through 9/4/25. Resident 1's Care Plan was reviewed. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, there were numerous observations of staff carrying uncovered dessert and fruit cups down hallways when meal trays were being delivered. On 9/2/25 at 12:20 PM, the hallway lunch service was observed and revealed the following: At 12:20 PM, the meal tray cart was parked outside of room [ROOM NUMBER]. An uncovered dessert on the meal tray was walked down the hallway to room [ROOM NUMBER]. At 12:31 PM, the meal tray cart was moved to be in between rooms [ROOM NUMBERS]. At 12:31 PM, an uncovered dessert on the meal tray was served to room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that, for 4 of 47 sampled residents, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive assessment, the comprehensive person-centered care plan, and the residents' choice. Specifically, a resident with an identified mass was not evaluated as requested by the resident representative; a resident was hospitalized after a failure to identify a change of condition in a timely manner; a resident's blood sample was not obtained per protocol which resulted in an emergency room visit; and a resident received medication in error and one medication rectally when oral medication was available. The deficient practice identified for residents 22 and 36 were found to have occurred at a harm level. Resident identifiers: 22, 36, 64 and 121.

Inspectors wroteBased on observation, interview, and record review it was determined, for 6 of 47 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a resident with previous falls from falling and sustaining a head laceration and neurological (neuro) checks were not completed as indicated. This deficiency was identified to have occurred at a harm level for resident 27. In addition, a resident who had fallen was moved before an assessment was completed by qualified personnel; the facility had hot water. In addition, facility environment disrepair identified resident accident hazards. Resident identifiers: 25, 27, 44, 47, 51 and 58. Findings Include: [...]

Inspectors wroteBased on interview, observation and record review, the facility did not ensure that 5 of 47 sample residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. Specifically, current weights were not being obtained to allow staff to appropriately assess the residents' nutritional status. In addition, interventions were not being implemented in a timely manner, residents were not being provided with the appropriate supplements, and were not assisted with meals . The findings for resident 53 were determined to have occurred at a harm level. Resident identifiers: 30, 31, 51, 53 and 121.

Inspectors wroteBased on interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented plans of action to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance for the same deficiencies identified in the last annual recertification survey. Resident identifiers: 22, 25, 27, 30, 31, 36, 44, 47, 51, 53, 58, 64 and 121.

Inspectors wroteBased on observation, interview and record review it was determined, for 6 of 47 sampled residents, that the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhanced of his or her quality of life, recognizing each resident's individuality. Specifically, a staff member escalated with a resident regarding financial concerns, residents were observed eating when another resident was bleeding in the dining room, staff were not knocking before entering resident rooms, residents voiced concerns regarding staff attitudes, and staff were observed yelling at each other in the hallways. Resident identifiers: 17, 22, 24, 39, 43 and 51.

Inspectors wroteBased on interview and record review, it was determined, the facility did not inform each resident periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, for 3 out of 3 sampled residents, a resident was not issued a Notice of Medicare Non-coverage (NOMNC) when the Medicare part A services were terminated. Resident identifiers: 38, 62, and 124.

Inspectors wroteBased on observation and interview, it was determined that the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, the facility environment was in disrepair which included resident safety hazards, there was lack of hot water, low water pressure in a sink and another sink did not have hot water. Resident identifiers: 36, 39, 40 and 64.

Inspectors wroteBased on interview and record review it was determined, for 1 of 47 sampled residents, that the did not ensure that each resident was free from abuse, neglect, misappropriate of resident property, and exploitation. Specifically, a resident was not provided medication, nutrition and fluids. Resident identifiers: 121.

Inspectors wroteBased on record review and interview it was determined, for 3 of 47 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA). In addition, report the results of all investigations to the SSA within 5 working days of the incident. Specifically, the facility did not report allegations of abuse within 2 hours of the incident. Resident identifiers: 9, 32 and 121.

Inspectors wroteBased on interview and record review it was determined, for 3 of 47 sampled residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to have evidence that all alleged violations were thoroughly investigated. Specifically, the facility did not thoroughly investigate an allegation of neglect, a resident who sustained a significant injury, and an elopement. Resident Identifiers: 9, 32 and 121.

Inspectors wroteBased on interview and record review, it was determined for 5 of 47 sampled residents that the facility did not ensure the comprehensive care plan included the services needed to achieve the highest practicable physical, mental and psychosocial well-being. Specifically, a resident was on a medication that required monitoring, which was not addressed in the comprehensive care plan; nutrition care plans were not developed, and vision care plans were not developed. Resident identifiers: 22, 51, 53, 170 and 268.

Inspectors wroteBased on observation, interview, and record review it was determined, for 5 of 47 sampled residents, that the facility did not provide the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless circumstances of the individual's clinical condition demonstrated that such diminution was unavoidable. Specifically, two residents did not receive showers as requested or as scheduled. In addition, residents were not provided assistance with nail care or dining. Resident identifiers: 15, 27, 30, 36, and 51. Findings Included: 1. Resident 27 was admitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, type 2 diabetes, anxiety disorder, major depressive disorder, obstructive sleep apnea, and vascular dementia. On 11/27/23 at 11:22 AM, an interview was conducted with resident 27's family member. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide sufficient staffing to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, it was determined that the facility did not provide sufficient nursing staff to meet the resident's needs in the areas of answering resident call lights in a timely manner; obtaining resident weights; or assisting the residents with their bathing. Resident Identifiers: 9, 30, 39, 53, 63, and 64.

Inspectors wroteBased on interview it was determined that the facility did not employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility did not a employ a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services.

Inspectors wroteBased on interview and record review, the facility did not ensure that the menus were followed. Specifically, residents who were prescribed a fortified diet, were not provided with the appropriate foods.

Inspectors wroteBased on observation, interview and record review it was determined, for 9 of 47 sampled residents, that the facility did not provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained of food quality, a test tray was bland and resident council minutes revealed complaints of food quality. Resident identifiers: 9, 10, 15, 17, 18, 32, 36, 39 and 64.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that food was prepared in a form designed to meet individual needs. Specifically, pureed foods were not prepared appropriately. Resident identifier: 36.

Inspectors wroteBased on interview and observation, the facility did not serve food that accommodated resident preferences. Specifically, three residents were provided meals that were inconsistent with their requests. Resident identifiers: 28, 60 and 123.

Inspectors wroteBased on interview and observation, the facility did not provide a nourishing snack at bedtime or upon request. Resident identifiers: 10, 18, 32 and 39.

Inspectors wroteBased on interview and observation, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, cross contamination was observed during the trayline process.

Inspectors wroteBased on interview and record review, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility assessment must address or include both the number of residents and facility's resident capacity; the care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that were present within that population; the staff competencies that were necessary to provide the level and types of care needed for the resident population; the physical environment, equipment, services, and other physical plan considerations that were necessary to care for this population; [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that all corridors were equipped with firmly secured handrails. Specifically, four handrails throughout the facility were found to be loose which created a resident safety hazard.

Inspectors wroteBased on interview and record review, the facility did not provide training to their nurse aides that was sufficient ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; include dementia management training and resident abuse prevention training; address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff; and address the care of the cognitively impaired.

Inspectors wroteBased on interview and record review it was determined, for 1 of 47 sampled residents, that the facility failed to provide residents the right to participate in the development and implementation of a person-centered plan of care, the right to attend meetings regarding the person-centered plan of care, and the right to request revisions to the person-centered plan of care. Specifically, a resident representative was not informed or included in care planning meetings in which concerns regarding the resident's plan of care could be discussed. Resident identifier: 22.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 47 sampled residents, that the facility did not ensure that the interdisciplinary team had determined that the resident's right to self administer medications was clinically appropriate. Specifically, a resident was observed to have medications on the bedside table in a medication cup and was not evaluated to determine if they were safe to self administer medications. Resident identifier:

Inspectors wroteBased on observation, interview, and record review, it was determined, for 1 of 47 sampled residents, that the facility failed to promote and facilitate self-determination through support of resident choice, including the right to make choices about aspects of their life in the facility that were significant to the resident. Specifically, a resident was not assisted in obtaining services to get their hair done. Resident identifier: 57.

Inspectors wroteBased on interview and record review it was determined, for 1 of 47 sampled residents, that the facility did not ensure each resident had the right to manage his or her financial affairs. Specifically, there was no system for staff to track how a resident with dementia's money was spent. Resident identifier: 43.

Inspectors wroteBased on interview and record review, the facility did not provide individual financial records through quarterly statements for 1 of 47 sample residents who had entrusted the facility with their personal funds. Resident identifier: 18.

Inspectors wroteBased on interview, the facility did not send a copy of resident 30-day discharge notices or hospitalizations to the Long-Term Care Ombudsman.

Inspectors wroteBased on interview and record review it was determined, for 1 of 47 sampled residents, that the facility did not develop and implement a baseline care plan within 48 hours of admission. Specifically, there were no baseline care plan created for a resident that was admitted for respite stay. Resident identifier: 121.

Inspectors wroteBased on interview and record review, the facility did not develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Specifically, a resident was not provided with assistance with relocation to a different facility despite multiple requests. Resident identifier: 8.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 47 sampled residents, that the facility did not provide the necessary care and services to ensure that activities of daily living that included hygiene: bathing, dressing, grooming, and oral care, were carried out to maximize the resident's functional abilities. Specifically, a resident was not provided oral care, assistance in using corrective lenses or ensuring the resident was wearing shoes. Resident identifier:

Inspectors wroteBased on interview and record review it was determined, for 1 of 47 sampled residents, that the facility did not ensure a resident received appropriate treatment and services to prevent urinary tract infections. Specifically, a resident with a positive urinary tract infection did not receive timely results for a urinalysis and a culture and sensitivity. Resident identifier: 17.

Inspectors wroteBased on interview and record review it was determined, for 1 of 47 sampled residents, that the facility did not ensure that a resident who received psychotropic drugs were not given these drugs unless the medication was to treat a specific condition as diagnosed and documented in the clinical record. Specifically, a resident was prescribed a psychotropic medication with an off label use and with out adequate monitoring. Resident identifier: 170.

Inspectors wroteBased on interview and record review it was determined, for 2 of 47 sampled resident, the facility did not ensure residents were free of any significant medication errors. Specifically, a dialysis resident was not administered their Renvela oral packet which was a phosphate binder as ordered by the physician. In addition, another resident was not administered their appropriate medications. Resident Identifiers: 21 and 121.

Inspectors wroteBased on interview and record review, for 2 of 47 sampled residents, the facility did not obtain laboratory services only when ordered by a physician. Specifically, resident's had laboratory services completed without a physician's order. Resident identifier: 36 and 121.

Inspectors wroteBased on interview and record review it was determined, for 2 of 47 sampled resident, that the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, residents with urinary tract infections were started on an antibiotic without Culture and Sensitivity results. Resident identifiers: 27 and 39. Findings Included: 1. Resident 27 was admitted on [DATE] with diagnoses which included cerebral infarction, hemiplegia and hemiparesis, type 2 diabetes, anxiety disorder, major depressive disorder, obstructive sleep apnea, and vascular dementia. Resident 27's medical record was reviewed 11/29/23 to 12/6/23. On 11/28/23 at 4:16 PM, a nurse note stated, regarding recent multiple falls. contusion/ bruising to the right side of forehead continues to heal routinely. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility did not have the nurse staffing information posted. The facility must post the following information on a daily basis: Facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses, Licensed practical nurses, Certified Nurse aides, and resident census. The facility must post the nurse staffing data on a daily basis at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Additionally, the information must be displayed in a prominent place readily accessible to residents and visitors.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility did not ensure a resident who was unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, for 1 out of 32 sampled residents, a resident was not provided with the necessary services related to incontinence care, which resulted in the resident acquiring Moisture Associated Skin Damage (MASD). Resident identifier: 167.

Inspectors wroteBased on interview and record review it was determined the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, for 1 out of 32 sampled residents, a resident that was dependant on renal dialysis missed a day of dialysis and had two critical potassium lab values with no interventions which resulted in death. Resident identifier: 111.

Inspectors wroteBased on interview and record review it was determined that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 3 out of 32 sampled residents, medications were not administered as ordered by the physician due to not being available by the pharmacy. Resident identifiers: 111, 112, and 113.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility's communal resident refrigerator contained items without proper labeling, and the resident communal snack refrigerator was maintained at a temperature higher than recommended standards.

Inspectors wroteBased on observation and interview it was determined the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff were observed without eye protection while working with residents on the Coronavirus Disease-2019 (COVID-19) unit, staff were observed to have dropped medications on the top of the medicine cart, staff picked up mediation with a bare hand and administered medications to a resident, and staff did not clean the end of an insulin pen prior to applying the needle for administration. Resident identifiers:

Inspectors wroteBased on interview and record review it was determined that the facility did not provide written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. Specifically, for 2 out of 32 sampled residents, a resident did not receive written notice prior to receiving a new roommate and a resident did not receive written notice prior to the room change. Resident identifiers: 12 and 112.

Inspectors wroteBased on interview and record review it was determined the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the Administrator of the facility and to other officials. Specifically, for 1 out of 32 sampled residents, an incident of employee to resident sexual abuse was not reported to the State Survey Agency or Adult Protective Services (APS) no later than 2 hours after the allegation was made. Resident identifier: 4.

Inspectors wroteBased on observation, interview, and record review it was determined the facility did not develop and implement comprehensive person-centered care plans for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 2 out of 32 sampled residents, the facility did not demonstrate implementation of care plan interventions related to a resident's incontinence, did not develop interventions within a resident's potential skin integrity impairment care plan, and did not update a resident's care plan related to the resident's nutrition risk. Resident identifiers: 51 and 167.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that a resident's discharge summary was complete. Specifically, for 1 out of 32 sampled residents, the resident's discharge summary did not include a recapitulation of the resident's stay, the final summary of the resident's status at discharge, a reconciliation of all medications, or a post-discharge plan of care. Resident identifier: 32.

Inspectors wroteBased on observation, interview, and record review it was determined the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, for 1 out of 32 sampled residents, a resident who had experienced a significant weight loss did not have interventions put in place to prevent further significant weight loss. Resident identifier: 51.

Inspectors wroteBased on interview and record review it was determined the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 32 sampled residents, the facility did not administer hypertensive medications when the blood pressure measurements were outside of the physician ordered parameters. Resident identifier: 22.

Inspectors wroteBased on interview and record review, the facility did not ensure the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance at a harm level with F677, which was cited within the facility's 2019 recertification survey. Also, the facility was found to be in non-compliance with F883, which was cited within an abbreviated, complaint survey completed on 2/9/21. Resident identifiers: 167.

Inspectors wroteBased on interview and record review it was determined the facility did not ensure that each resident's medical record included documentation that indicated the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations. Specifically, for 1 out of 32 sampled residents, the medical record did not include documentation that information or education was provided regarding the benefits, risks, and potential side effects of the influenza and pneumococcal immunizations. In addition, the medical record did not included the administration or the refusal of the immunizations. Resident identifier: 47.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility did not ensure all mechanical, electrical, and patient care equipment were kept in safe operating condition. Specifically, the facility was unable to ensure a resident had a functioning bed while at the facility. Resident identifier: 2.

Inspectors wroteBased on observation and interview it was determined the facility did not ensure that resident rooms were designed and equipped for adequate nursing care, comfort, and privacy of resident. Specifically, for 1 out of 32 sampled residents, the staff were storing the residents walker and wheelchair in the hallway outside of the residents room when they were not in use. Resident identifier: 113.

Inspectors wroteBased on observation and interview it was determined the facility did not ensure that a single resident room measured at least 100 square feet. Specifically, for 1 out of 32 sampled residents, the resident's usable living space of the room measured under 100 square feet. Resident identifier: 113.

Inspectors wroteBased on observation and interview it was determined the facility did not ensure that a resident bedroom had at least one window to the outside. Specifically, for 1 out of 32 sampled residents, a resident bedroom did not have a window to the outside. The window was located within the resident bathroom and was unable to be seen from the resident bed. Resident identifier: 113.