Monument Healthcare Bountiful: Abuse Response Failures - UT
Monument Healthcare Bountiful reported the September incident to state authorities as required, but federal inspectors found the facility's abuse investigation contained critical gaps that prevented them from determining whether neglect occurred.
Resident 2 fell from a Hoyer lift sling on September 22 while two certified nurse assistants were transferring her from bed to wheelchair. The resident hit the floor and landed on her back, slightly on her right side.
The nursing staff who responded found the resident complaining of pain to her left knee and right hip. About 30 minutes after the fall, they discovered a "goose egg" on the back left side of her head.
X-rays were ordered for her right shoulder, right hip, and both knees. The resident had already sustained a fracture of the right femur before this incident, according to her medical record.
But when inspectors reviewed the facility's investigation seven weeks later, they found no documentation of interviews with either CNA 1 or CNA 2, the two staff members who were operating the Hoyer lift when the resident fell.
The investigation summary claimed that staff conducted an interview with the resident herself, but inspectors could find no record of that conversation either.
"The investigation documentation did not contain copies of the interviews that were completed," the Director of Nursing confirmed to inspectors on November 5.
Federal regulations require nursing homes to thoroughly investigate all allegations of neglect and maintain documentation proving they examined every aspect of an incident. The missing interviews meant the facility couldn't demonstrate it had ruled out whether staff negligence contributed to the fall.
The DON told inspectors she conducted staff interviews, inspected the sling and Hoyer lift equipment, and provided retraining to every CNA on proper Hoyer use. The training emphasized checking the sling for damage and ensuring proper placement before each transfer.
Yet none of this critical investigative work appeared in the facility's official documentation.
The facility also got basic facts wrong in its reporting. The interdisciplinary team's fall review documented the incident occurring at 8:00 AM on September 22, but the nursing notes recorded it at 7:36 AM. When the facility reported to the State Survey Agency, they said it happened on September 29 at 1:45 PM.
Resident 2 had been admitted to Monument Healthcare Bountiful with complex medical conditions including type 2 diabetes, major depressive disorder, respiratory failure, difficulty swallowing, and paralysis affecting one side of her body. She required mechanical lift assistance for transfers due to her mobility limitations.
Hoyer lifts use fabric slings to move residents safely from beds to wheelchairs or other locations. The equipment requires two staff members working together to ensure the sling is properly positioned and secured before lifting begins.
The resident's medical record showed she was already being monitored for bruising to her right buttock that existed before the September fall. After the incident, staff applied ice as needed and administered pain medications.
The DON acknowledged to inspectors that the facility is mandated to report incidents to the State Survey Agency to identify problems including harm, neglect, and policy failures. But she admitted "it was not evident that they investigated the incident for possible neglect."
When asked about the missing interview documentation, the DON said she would need to ask the previous administrator where those records were located.
The inspection occurred following a complaint about the facility's handling of the incident. Federal inspectors determined Monument Healthcare Bountiful failed to respond appropriately to alleged violations by conducting a thorough investigation.
The missing documentation meant inspectors couldn't verify whether the facility had properly examined all circumstances surrounding the fall or whether staff actions met acceptable standards of care.
Mechanical lift accidents can result from equipment malfunction, improper sling placement, inadequate staff training, or failure to follow safety protocols. Without interviewing the staff members who were present, the facility couldn't determine which factors contributed to this resident's fall and injuries.
The resident sustained multiple injuries from the incident, including the head injury that wasn't discovered until 30 minutes after the fall occurred. She experienced pain in multiple locations and required medical imaging to assess for fractures.
Federal regulations specify that nursing homes must have evidence that all alleged violations were thoroughly investigated when responding to complaints of neglect or abuse. The documentation gaps at Monument Healthcare Bountiful prevented inspectors from confirming the facility met this requirement.
The facility's investigation summary indicated two CNAs were present during the transfer, but their perspectives on what went wrong remained undocumented in the official record. Their accounts could have revealed whether equipment failed, protocols weren't followed, or other factors contributed to the resident falling from the lift.
Monument Healthcare Bountiful serves residents requiring various levels of care in Bountiful, located about 10 miles north of Salt Lake City. The facility provides skilled nursing and rehabilitation services.
The inspection found the facility's investigation practices created minimal harm or potential for actual harm to residents. But the missing documentation prevented a complete assessment of whether neglect occurred during the mechanical lift transfer.
Without proper investigation records, the facility couldn't demonstrate it had identified and corrected any system failures that might lead to similar incidents. The resident who fell required ongoing medical treatment for her injuries while the facility's incomplete investigation left questions about the incident's cause unresolved.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monument Healthcare Bountiful from 2025-11-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Monument Healthcare Bountiful in Bountiful, UT was cited for abuse-related violations during a health inspection on November 6, 2025.
Resident 2 fell from a Hoyer lift sling on September 22 while two certified nurse assistants were transferring her from bed to wheelchair.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.