Monument Healthcare Bountiful

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 out of 6 sampled residents, that the facility did not ensure that each resident received supervision and assistance devices to prevent accidents. Specifically, a resident sustained a fall which resulted in a fracture during a one-person assisted transfer in a Hoyer lift and it was determined that the lift was missing safety latches on the cradle hooks. Resident identifier: 2. NOTICEOn [DATE] at 10:38 AM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to ensure that each resident received adequate supervision and assistance devices to prevent accidents. Notice of IJ was given verbally and in writing to the facility Administrator (ADM), Director of Nursing (DON), and the Regional Compliance Nurse (RCN). [...]

Inspectors wroteBased on interview and record review it was determined, for 1 out of 6 sampled residents, the facility did not ensure that all alleged violations involving neglect were reported no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Specifically, a resident sustained a fall which resulted in a fracture during a one-person assisted transfer in a Hoyer lift and the State Survey Agency (SSA) and Adult Protective Services (APS) were not notified within 24 hours of the incident. Resident identifier: 2.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 6 sampled residents, that in response to allegations of neglect the facility must have evidence that all alleged violations were thoroughly investigated. Specifically, a resident sustained a fall which resulted in a fracture during a one-person assisted transfer in a Hoyer lift and the facility abuse investigation did not contain documentation of all staff and resident interviews that were conducted to rule out neglect. Additionally, the abuse investigation incorrectly documented the date of the incident.

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure that all residents had appropriate supervision to prevent accidents. Specifically, one resident was being pushed in a wheelchair without footrests by facility staff, and the resident fell out of the wheelchair, hitting her face, causing scrapes and a lip laceration. Resident identifier: 2. In response to the incident involving Resident 2, the facility identified the quality deficiency and developed a corrective action plan. At the time of the complaint survey, it was determined that the facility had implemented corrective measures and met the requirements of F689. Due to the facility's corrective measures, the noncompliance was determined to be past noncompliance. The facility's corrective action plan, which was developed and implemented by May 10, 2025, included the following measures: a. [...]

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure that each resident was free from significant medication errors. Specifically, a nurse administered the incorrect medications to a resident. Resident identifiers: 1 In response to the incident involving Resident 1, the facility identified the quality deficiency and developed a corrective action plan. At the time of the complaint survey, it was determined that the facility had implemented corrective measures and met the requirements of F760. Due to the facility's corrective measures, the noncompliance was determined to be past noncompliance. The facility's corrective action plan, which was developed and implemented by May 17, 2025, included the following measures: a. The nurse involved in the incident was removed from the facility staff. b. Medication training was implemented for both current and new staff. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 18 sampled residents, a resident slid out of her wheelchair during a transport and sustained a femur fracture. Resident identifier:

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that pain management was provided to residents who required services consistent with professional standards of practice and the comprehensive person-centered care plan and the resident's goals and preferences. Specifically, for 1 out of 18 sampled residents, a resident was not provided pain medications prior to wound care treatments nor afterwards and the resident had complaints of pain throughout the treatment. Resident identifier: 42.

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the State Survey Agency (SSA). Specifically, for 1 out of 18 sampled residents, the facility did not report to the SSA when a resident sustained a fracture during a transportation. Resident identifier:

Inspectors wroteBased on interview and record review, the facility assessment did not accurately reflect the resident's status. Specifically, for 2 out of 18 sampled residents, a resident who was receiving hospice services was not coded on two quarterly Minimum Data Set (MDS) assessments and an annual MDS assessment as receiving hospice services. In addition, a resident that had a Preadmission Screening and Resident Review (PASRR) Level II was not coded on the MDS as having one. Resident identifiers: 22 and 27.

Inspectors wroteBased on interview and record review, the facility did not file in the resident's clinical record signed and dated reports of radiological services. Specifically, for 1 out of 18 sampled residents, a resident's x-ray report was not located in the medical record. Resident identifier:

Inspectors wroteBased on observation, interview, and record review, the facility did not 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, for 1 out of 18 sampled residents, hand hygiene and donning and doffing of Personal Protective Equipment (PPE) was not performed appropriately during a wound care treatment observation. Resident identifier: 42.

Inspectors wroteBased on observations and interviews it was determined, for 5 of 18 sample residents, that the facility did not ensure safe and secure storage of drugs and biological's in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, there were opened multi-dose vials of medication available for use without a documented open date. Resident Identifiers: 8, 21, 24, 34, and 96.

Inspectors wroteBased on observation and interview it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, a staff member was observed to not perform hand hygiene after touching dirty dishes and was observed to hold clean dishes against a plastic apron that was dirty. In addition, there was dust on the vents above the food preparation area and there were items not dated in the refrigerators.

Inspectors wroteBased on observation, interview, and record review 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 prevent the development and transmission of communicable diseases and infections. Specifically, staff members were observed to touch resident medications with bare hands and staff did not clean the top of an insulin vial prior to drawing up the insulin for administration. Resident identifiers:

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 18 sample residents, that the facility did not ensure the prompt resolution of grievances. Specifically, a resident expressed a grievance regarding the roommates television being too loud. The grievance was expressed to multiple staff members and social services. There was no grievance filed and there was no resolution to the grievance. Resident identifier: 25.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 out of 18 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, one resident sustained a left foot injury while being transported in the shower chair. Resident identifier: 23 Findings Included: Resident 23 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side, type 2 diabetes mellitus, generalized anxiety disorder, muscle weakness, and major depressive disorder. On 3/13/23 at 10:15 AM, an interview was conducted with resident 23. Resident 23 stated that he did not feel safe on the shower chair and described them as rickety. [...]

Inspectors wroteBased on observation, interview and record review it was determined, for 3 of 19 sampled residents, that the facility did not ensure each resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Specifically, residents' positioning bars were removed from their beds resulting in residents not being able to reposition themselves. Resident identifiers: 20, 29 and 36.

Inspectors wroteBased on observation and interview it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, areas in the kitchen were soiled, ants were observed on the floor, and cracked tiles and missing grout were observed.

Inspectors wroteBased on observation and interview, the facility did not 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, appropriate Personal Protective Equipment (PPE) was not worn, and cross contamination occurred during a medication pass.

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility did not provide residents with the appropriate treatment and services to maintain or improve their abilities to carry out activities of daily living. Specifically, for 1 out of 19 sample residents, the facility did not ensure the resident received 2-person assistance with bed mobility consistent with the resident's needs and choices. Resident identifier: 32.

Inspectors wroteBased on interview and record review it was determined, for 2 of 19 sampled residents, that the facility did not file clinical record laboratory reports that were dated in residents' clinical record. Specifically, residents had orders for laboratory values that were not located in the medical record. Resident identifiers: 23 and 31.