Monument Healthcare South Salt Lake

Inspectors wroteBased on interview and record review, for 1 out of 6 sampled residents, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident who was dependent on staff for bed mobility and repositioning fell out of bed during a bed bath while being assisted by one staff member. Resident identifier: 6. The facility developed and implemented a corrective action plan before the survey start date. The facility's corrective action plan, which was developed and implemented by 5/1/2026, included the following measures: conducting a house-wide audit on mechanical lifts, air mattresses, bed-bound residents, and heavier residents; [...]

Inspectors wroteBased on observation, interview, and record review, 20 of 61 sampled resident, that the facility failed to ensure residents were providing supervision to prevent accidents. Specifically, hot water temperatures in resident rooms throughout the facility were observed to range in temperatures from 121.7-145.5 degrees Fahrenheit. This deficient practice occurred at an Immediate Jeopardy level. In addition, residents who were assessed as requiring supervision while smoking were observed smoking unsupervised, a resident was not evaluated for smoking and was observed smoking, residents with a history of wandering eloped from the facility without staff knowing, the front doorbell was not working and residents were locked outside unable to alert staff, and metal bed frames and boxes were stored in a dayroom that residents were observed to be in. Resident Identifiers: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Specifically, a staff and public restroom had extremely hot water temperatures.

Inspectors wroteBased on observation, interview, and record review, it was determined that for 2 of 61 sampled residents, the facility did not ensure residents who displayed or were diagnosed with mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Specifically, a resident who was diagnosed with mental disorders was observed to be at the end of a hallway for hours with a urine odor yelling at staff and residents, was not provided her psychotropic medication, and did not follow up on a Nurse Practitioner's recommendation of inpatient psychiatric admission. Resident identifiers: 48 and 59.

Inspectors wroteBased on observation, interview and record review it was determined the facility did not provide or obtain laboratory services to meet the needs of its residents. If the facility provided its own laboratory services, the services must meet the applicable requirement for laboratories. Specifically, facility glucometers were not being calibrated according to the manual.

Inspectors wroteBased on interview and observation, the facility did not treat residents with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, residents dining in the dining room were served beverages in Styrofoam cups and prepackaged juice cups.

Inspectors wroteBased on interview and record review, for 3 out of 61 sampled residents, the facility did not ensure that all alleged violations involving abuse and neglect were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, notification to the SSA and APS was not done when a resident eloped from the facility and another resident alleged that a Certified Nursing Assistant (CNA) put their fingers into her private parts. Additionally, a resident eloped from the facility and APS was not notified. Resident identifiers: 64, 113, and 115.

Inspectors wroteBased on observation, interview, and record review, it was determined for 4 of 61 sampled residents, that the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. Specifically, three resident's eye drops and one resident's insulin were expired. Resident identifiers: 31, 44, 106, and 107.

Inspectors wroteBased on observation, interview and record review the facility did not ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Specifically, sanitizer solution was not measuring on the testing strips, there were soiled areas in the kitchen and spices were left open to air.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that policies were established and implemented to ensure that identified deficiencies were corrected. Specifically, areas of immediate jeopardy (IJ) were identified and not identified through the Quality Assurance and Performance (QAPI) process. In addition, multiple areas of non compliance were cited on the previous survey and again during the current recertification survey.

Inspectors wroteBased on interview and record review, it was determined for 2 of 61 sampled residents, that the facility failed to ensure each resident had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. Specifically, one resident representative was not informed in advance of starting an antidepressant medication and another resident representative was not informed in advance of a wanderguard being placed. Resident identifiers: 82 and 103.

Inspectors wroteBased on interview and record review, it was determined, 1 of 61 sampled residents, the facility failed to keep residents free from abuse. Specifically, a Registered Nurse (RN) employee had a sexual relationship with a resident who resided in the facility. Resident identifier: 118Based on interview and record review, it was determined, 1 of 61 sampled residents, the facility failed to keep residents free from abuse. Specifically, a Registered Nurse (RN) employee had a sexual relationship with a resident who resided in the facility. Resident identifier: 118Findings included:On 3/28/25 at 12:22 PM, the facility reported that on 3/28/25 at 10:00 AM an investigator from the Division of Professional Licensing (DOPL) came into the facility on a complaint from resident 118. It was reported to DOPL that RN 3 had been sexually inappropriate with resident 118. [...]

Inspectors wroteBased on interview and record review, it was determined for 2 out of 61 sampled residents, that the facility did not notify the resident of the discharge and the reasons for the move in writing and in a language and manner they understand; or send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman as soon as practicable or when a resident had not resided in the facility for 30 days. Specifically, the Ombudsman was not notified when one resident was discharged to the hospital and the ombudsman was not notified of a resident's discharge and the reasons why the resident left the facility. Resident identifiers: 54 and 113.

Inspectors wroteBased on interview and record review, it was determined for 1 of 61 sampled residents, that the facility failed to ensure the assessment accurately reflected the resident's status. Specifically, a diagnosis of depression was not included on the assessment. Resident identifier: 82.

Inspectors wroteBased on observation, interview and record review, for 1 of 61 sampled residents, the facility did not provide care and services to maintain or improve a resident's ability to carry out the activities of daily living. Specifically, a resident's bed was positioned against a wall so that his inoperable hand was facing his environment, diminishing his abilities in activities of daily living. Resident identifier: 67.

Inspectors wroteBased on observation, interview and record review, for 1 out of 61 sampled residents, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and resident's choices. Specifically, a resident's diabetes was not managed with required documentation, timely referral to outside services or diet management according to physician's orders and resident's choice. Resident identifier: 36.

Inspectors wroteBased on observation, interview and record review, for 2 out of 61 sampled residents, the facility did not ensure that residents were offered a therapeutic diet when the therapeutic diet was ordered. Specifically, a resident on a diabetic diet was not provided a low carbohydrate option. In addition, a resident complained of not being provided a renal diet. Resident identifier: 36 and 79.

Inspectors wroteBased on interview, and record review, it was determined that for 1 of 61 sampled residents, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, a resident did not have an Invega injection available when it was scheduled to be administered. Resident identifiers: 59.

Inspectors wroteBased on interview and record review, for 2 of 61 sampled residents, the facility did not arrange services with an outside agency in a timely manner. Specifically, a resident that needed dental services did not have those services scheduled, and a resident did not have an endocrinology appointment scheduled after a referral from the physician. Resident identifiers: 36 and 64.

Inspectors wroteBased on interview and record review, it was determined for 2 of 61 sampled residents, that the facility failed to maintain medical records on each resident that was complete, accurately documented, readily accessible, and systematically organized; and failed to ensure the medical record contained the results of any preadmission screening and resident review evaluations and determinations conducted by the State; and physician, nurse, and other licensed professionals progress notes. Specifically, one resident had an updated Pre-admission Screening/Resident Review (PASRR) that was not located in the medical record and one resident had no documentation regarding an elopement. Resident identifiers: 82 and 103.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe and sanitary environment to prevent the potential transmission of communicable diseases and infections for 1 out of 61 sampled residents. Specifically, staff were not wearing Enhanced Barrier Precautions (EBP) for a resident with chronic wounds and a tube feed when caring for the resident and the tube feed was not capped when not in use. Resident identifier: 90.

Inspectors wroteBased on interviews and record review, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, for 1 out of 26 sampled residents, a resident did not have interventions in place to prevent a deep tissue ulcer/injury to the left inner buttocks from developing and treatments to prevent it from getting worse were not completed. Resident identifier: 143.

Inspectors wroteBased on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. In addition, the facility did not ensure that all drugs and biologicals were stored under proper temperature controls. Specifically, opened insulin vials were not labeled with open dates and the insulin vials were in the medication cart available for resident use. In addition, the medication refrigerator was found to have low temperatures not compatible with medication storage and a pill was observed on the floor in the hallway accessible to residents.

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer were open to air and the resident refrigerator was unclean and contained unlabeled and undated food items.

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 2 hours after the allegation was made to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, for 1 out of 26 sampled residents, notification to the SSA and APS was not done when a resident with cognitive impairment eloped from the facility. Resident identifier: 7.

Inspectors wroteBased on interviews and record review, the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, and be developed within 48 hours of the resident's admission. Specifically, for 1 out of 26 sampled residents, a resident's baseline care plan was developed four days after the resident admitted to the facility. Resident identifier: 143. Resident 143 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included benign neoplasm of meninges, pressure ulcer of left buttock stage 4, and cognitive communication deficit. Resident 143's medical record was reviewed on 1/23/24. [...]

Inspectors wroteBased on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan consistent with the resident rights that included measurable objectives and timeframe's to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 1 out of 26 sampled residents, the resident's Care Area Assessment (CAA) Summary of the admission Minimum Data Set (MDS) assessment triggered a care plan for pressure ulcer/injury and the care plan was not developed until 5/8/23, after the resident developed a pressure ulcer/injury. Resident identifier: 143.

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents. Specifically, for 1 out of 26 sampled residents, a resident with cognitive impairment eloped from the facility on two separate occasions. Resident identifier: 7.

Inspectors wroteBased on interview and record review, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 2 out of 26 sampled residents, medications were not administered as ordered by the physician due to the medications not being available by the pharmacy. One resident was not administered their mood disturbance medication, anti-tremor medication, and a medication for sleep. In addition, a resident was not administered their blood thinning medication to prevent blood clots and an antibiotic that was used to treat a wound infection. Resident Identifiers: 7 and 143. Findings Included: 1. [...]

Inspectors wroteBased on observation and interview, 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 members were observed to touch the resident's medications and the inside of the medication cups with bare hands during medication administration. Resident identifier: 9.

Inspectors wroteBased on observation, interview, and record review it was determined, for 4 out of 51 sample residents, that the facility did not ensure that the residents were free from abuse and neglect. Specifically, two residents were engaged in sexual activity without the consent of one resident and neither resident had been assessed for the capacity to consent to the sexual activity. Additionally, a resident was heard crying out in pain for over 4 hours and the nurse did not notify the physician to obtain an order for pain medication, having stated that the resident was drug seeking and attention seeking. The above examples were found to have occurred at a harm level. Lastly, a resident sustained a bruise that resulted from an improper transfer. Resident identifiers: 15, 19, 194, and 196.

Inspectors wroteBased on interview and record review, the facility did not ensure that 3 of 51 sample residents received treatment and care in accordance with professional standards of practice and the residents' choices. Specifically, a resident with a recent history of hospitalization for strokes was not assessed and was discharged against medical advice when a family member requested the resident be taken to a local hospital. The findings for this resident were determined to have occurred at a harm level. In addition, a resident did not receive treatment for low blood glucose levels, and another resident did not receive appropriate treatment for a diabetic ulcer. Resident identifiers: 4, 198 and 201.

Inspectors wroteBased on observation, interview, and record review it was determined, for 3 of 51 sample residents, that the facility did not provide a resident with pressure ulcers the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. Specifically, staff did not notify the provider or wound care nurse of a resident's worsening pressure ulcer in a timely manner, resulting in the delay of necessary and appropriate treatment and services. In addition, the resident continued to receive treatment inappropriate for the worsening pressure ulcer due to staff not notifying the provider or wound care nurse in a timely manner. The deficient practice identified was found to have occurred at a harm level. Resident identifier: 36, 76 and 82.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 51 sample residents, that the facility did not ensure that pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a resident was observed to cry out in uncontrolled pain for over 4 hours and the licensed nurse would not notify the physician of the resident's condition to request any new orders for pain medication. Resident identifier 194.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 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 F684, F679, F686 and F600. In addition, several deficiencies were cited during the 2019 recertification survey, and again during the 2022 survey. Resident identifiers:

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, the dishwasher did not meet the required minimum temperatures during the wash cycle.

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, interview and record review it was determined, for 5 of 51 sample residents, that residents were not able to make choices about aspects of their life in the facility that were significant to residents. Specifically, the facility did not allow residents to smoke independently after being evaluated. In addition, a resident requested coffee and was not provided it. Resident identifiers: 47, 51, 52, 59 and 196.

Inspectors wroteBased on interviews and record review it was determined, for 4 of 51 sample residents, that the facility did not immediately consult with the resident's physician when residents experienced a significant change in physical, mental, or psychosocial status. Specifically, the physician was not notified for 8 days of a resident's worsening wound condition and the physician was not notified when a resident experienced low blood glucose levels. In addition, the physician was not notified a resident was screaming out in pain during the night and the physician was not notified a open wounds on a resident's foot. Resident identifier: 4, 76, 194 and 198.

Inspectors wroteBased on observation, interview, and record review it was determined, for 12 of 51 sample residents, that the facility did not provide a safe, clean, comfortable, and homelike environment, allowing the residents to use his or her personal belongings to the extent possible. Specifically, there were multiple complaints from residents and observations of rooms in the facility that were unclean, needed to be repainted, and had a urine odor. Additionally, certain areas in the facility had holes in the walls, and sinks that did not drain. Resident identifiers: 10, 15, 23, 41, 51, 58, 62, 68, 72, 82, 198 and 200.

Inspectors wroteBased on interview and record review it was determined, for 4 of 51 sampled residents, that the facility did not implement written policies and procedures that prohibit and prevent abuse and neglect. Specifically, the facility did not demonstrate implementation of their abuse policy through timely investigation and reporting of suspected abuse to the Administrator (ADM), State Survey Agency (SSA), and Adult Protective Services (APS). Resident identifiers: 15, 19, 194, and 196.

Inspectors wroteBased on interview and record review it was determined, for 3 out of 51 sampled residents, that the facility did not ensure that all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegation was made, to the administrator (ADM) of the facility and to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, an incident of sexual abuse, an incident of neglect with verbal abuse, and an incident of physical abuse were not reported to the ADM, SSA or APS within 2 hours after the identification or occurrence of the incident happening. Resident identifiers: 19, 194, and 196.

Inspectors wroteBased on observation, interview and record review, it was determined that, for 3 of 51 sampled residents, the facility did not develop and implement a comprehensive person-centered care plan for each resident that described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, a resident who was observed to be smoking was not identified as a smoker did not have a smoking care plan. In addition, the facility staff did not update a resident's care plan in a timely manner when a wound requiring treatment was identified and a resident with limited range of motion did not have interventions for therapy and splints on the care plan. In addition, Resident identifiers: 23, 38 and 76.

Inspectors wroteBased on interview and record review it was determined, for 4 of 51 sampled residents, that the facility did not provide the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADL's). Specifically, resident showers were not being completed according to their shower schedule. Resident identifiers: 41, 64, 82, 198.

Inspectors wroteBased on observation, interview and record review it was determined, for 10 of 51 sample residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skill set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physicial, mental, and psychosocial well-being of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity and diagnosies of the facility's resident population in accordance with the facility assessment. Specifically, there was no facility asssessment to determine staffing needs for resident. Resident identifiers: 6, 9, 15, 29, 36, 58, 62, 194, 198 and 201.

Inspectors wroteBased on observations and interview it was determined that, for 12 of 51 sampled residents, that the facility did not provide food prepared by methods that conserve nutritive value, flavor, and appearance; food and drink that was not palatable, attractive, and at a safe and appetizing temperature. Specifically, multiple residents complained about the palatability of the food, appearance of the food, and repetition of meals. Resident identifiers: 4, 10, 15, 32, 36, 48, 51, 58, 62, 64, 80 and 81.

Inspectors wroteBased on interview and record review it was determined that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of COVID-19. Specifically, food was observed to be transported through the hallways uncovered, the staff were observed entering resident rooms without proper Personal Protective Equipment (PPE), and soiled PPE was observed to be transported through the hallways, and resident care equipment was not sanitized.

Inspectors wroteBased on observation, interview and record review it was determined, for 2 of 51 sample residents, that the facility did not treat each resident with respect, dignity and care, in a manner and in an environment that promoted maintenance and enhancement of his or her quality of life. Specifically, residents were observed to have urine soaked beds. Resident identifiers: 58 and 82.

Inspectors wroteBased on interviews and record reviews it was determined, for 1 of 51 sample residents, that the facility failed to assure Pre-admission Screening and Resident Review (PASARR) screening was accurately completed. Resident identifiers: 16.

Inspectors wroteBased on interview and record review it was determined, for 1 of 51 sample residents, that the facility did not develop a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care. Specifically, a resident had wounds identified on their admission assessment and the baseline care plan did not address the skin condition or wound care treatment. Resident identifier: 198.

Inspectors wroteBased on interview and record review, it was determined, for 1 of 51 sample residents, that the facility did not ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, a resident was not provided showers according to their schedule. Resident identifier: 36.

Inspectors wroteBased on interview and record review it was determined, for 1 of 51 sample residents, that the facility did not ensure residents received proper treatment and care to maintain good foot health. Specifically, staff did not review the podiatrist's recommendations in a timely manner, resulting in the delay of proper treatment of a resident's foot issues. Resident identifier: 76.

Inspectors wroteBased on observation, interview, and record review, it was determined, for 2 of 51 sample residents, that the facility did not ensure that residents with limited range of motion received appropriate treatment and services to increase and/or prevent further decrease in range of motion. In addition, the facility did not ensure that residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence. Specifically, a resident with limited range of motion did not have a splint that was recommended by Occupational Therapy. In addition, a resident was not provided bilateral positioning bars so she was able to reposition herself. Resident identifiers: 23 and 48.

Inspectors wroteBased on interviews, observations, and record reviews it was determined that, for 2 of 51 sampled residents, the facility did not 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 was observed smoking without protective equipment that he was assessed to need. In addition, another resident was observed smoking and did not have a smoking assessment. Resident identifier: 5 and 38.

Inspectors wroteBased on observation, interview and record review it was determined, for 2 of 51 sample residents, that the facility did not ensure based on resident's comprehensive assessment, that a resident who was incontinent received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, a resident was evaluated to be a good candidate for a bladder retraining program and the resident was not provided the program. In addition, the resident and another resident were observed to be in urine soaked beds. Resident identifiers: 58 and 82.

Inspectors wroteBased on interview and record review the facility did not establish an infection prevention and control program that included an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for 1 of 51 sample residents. Specifically, a resident was receiving an antibiotic prophylactically, with no indication for use or periodic review of the necessity of the antibiotic. Resident identifier: 4.

Inspectors wroteBased on interview and record review it was determined, for 1 of 51 sample resident, that the facility did not follow the Centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices (ACIP) guidelines to offer pneumococcal immunizations. Specifically, a resident had no record of receiving the pneumococcal vaccine per CDC and ACIP guidelines. Resident Identifier:

Inspectors wroteBased on observation, interview, and record review, it was determined, for 1 of 51 sample residents, that the facility did not have each bed with ceiling suspended curtains, which extended around the bed to provide total visual privacy in combination with adjacent walls and curtains. Specifically, the curtains in a resident's room did not have the ability to close all the way, leaving the resident to not have full visual privacy. Resident identifier: