Monument Healthcare South Salt Lake

In the surveyor’s words

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

• Immediate jeopardy, widespreadF689Jun 19, 2025

  Based 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… […]

• Immediate jeopardy, patternF921Jun 19, 2025

  Based 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. These findings were found to have occurred at an Immediate Jeopardy (IJ) Level. NOTICE:Notice of Immediate Jeopardy (IJ) was given verbally to the Administrator on 6/10/25 at 2:30 PM. The Administrator was asked to develop an immediate plan to ensure resident safety related to hot water temperatures. […]

• Actual harm, isolatedF742Jun 19, 2025

  Based 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. […]

• Actual harm, isolatedF686Jan 25, 2024

  Based 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. […]

• Actual harm, isolatedF600Mar 21, 2022

  Based 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . The above examples were found to have occurred at a harm level. Lastly, a resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident identifiers: 15, 19, 194, and 196. Findings included: HARM 1. […]