Monument Healthcare Brigham City

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Apr 16, 2024

  Based on interview and record review, the facility did not ensure that the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, for 1 out of 27 sampled residents, staff were unable to locate a resident for a period of time. There was an area of the facility that was locked an unaccessable to staff. There was a facility staff member in the locked area that the resident was observed to exit from. The resident made statements that the staff member engaged in sexual actions with her. In addition, the staff member had been talked to about not remaining in the facility after dinner time. This example was cited at Immediate Jeopardy. […]

• Actual harm, isolatedF600Dec 3, 2025

  Based on interview and record review, it was determined that for 1 out of 13 sampled residents, the facility did not ensure residents had a right to be free from neglect. Specifically, a resident was left in a wet brief for an extended period of time and sustained a rash and excoriation to the groin. This resulted in a finding of harm for the resident. Resident identifier: 9.Findings included: Resident 9 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, unspecified urinary incontinence, mild cognitive impairment of uncertain or unknown etiology, and cognitive communication deficit.Resident 9's medical record was reviewed on 12/3/25.On 3/13/25 at 10:00 PM, a progress note documented, Oncoming aides rounded on resident and… […]

• No harm, potential for more than minimal, widespreadF812Apr 16, 2024

  Based on observation, interview, and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dish machine washing temperature was not manufacture required temperature and there were no sanitizer strips available to test the solution. Findings included: 1. On 4/8/24 at 9:03 AM, an initial tour of the kitchen was conducted. The following observation was made of the dish machine [Note: All temperatures were in degrees Fahrenheit.] a. The washing temperature was 110 and the rinse temperature was 120. There were 11 plates, five cups, one dessert dish, and a lid that were in the dish machine. An observation was made of the Dietary Manager (DM) replacing the dishes with the clean dishes. […]

• No harm, potential for more than minimal, patternF689Jul 1, 2026

  Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible, and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 2 out of 20 sampled residents, the facility failed to implement new or revised interventions after consecutive falls. In addition, the locked unit was left without nursing staff supervision for multiple periods of time and a resident wandered into other resident's rooms. Resident identifiers: 13 and 21.Findings included:1. […]

• No harm, potential for more than minimal, patternF812Jul 1, 2026

  Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, hand hygiene was not done according to professional standards and there were soiled areas in the kitchen. Findings include:1. On 6/29/26 at 10:00 AM, an initial tour was conducted of the kitchen. The following was observed:a. The vents above the grill were observed to have dust on them.b. There were large bins labeled oatmeal, powdered sugar, flour and sugar that were observed to be soiled on the outside. c. Celery Seed and Mediterranean style ground oregano spices were open to air. d. The juice machine compressor had crumbs and debris on it. The compressor was on a tray that had crumbs and debris. 2. […]