Monument Healthcare Bountiful

In the surveyor’s words

From the most serious findings on record at Monument Healthcare Bountiful, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 6, 2025

  Based 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. […]

• Actual harm, isolatedF689Jun 9, 2025

  Based 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. […]

• Actual harm, isolatedF689Dec 18, 2024

  Based 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: 20 Finding included: Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include, but not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, atherosclerotic heart disease, type 2 diabetes mellitus, unspecified asthma, fatty liver, anxiety disorder, major depressive disorder, essential hypertension, muscle weakness, and cognitive communication deficit. […]

• Actual harm, isolatedF697Dec 18, 2024

  Based 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. […]

• Actual harm, isolatedF600Feb 10, 2022

  Based on observation, interview and record review it was determined, for 1 out of 29 sampled residents, that the facility failed to ensure that a resident was free from abuse. Specifically, a resident reported experiencing repeated incidents of verbal abuse from another resident along with an incident of physical abuse. The deficient practice identified was found to have occurred at a harm level. Resident identifier 13 and 22. Findings included: 1. Resident 22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/07/22 at approximately 11:45 AM, an interview was conducted with resident 22. Resident 22 stated no when asked if she had any concerns or problems with any of the other residents in the facility, and if anyone had treated her badly. […]