Monument Healthcare Bountiful: Immediate Jeopardy - UT
The fall happened on September 22 at Monument Healthcare Bountiful when two certified nursing assistants were transferring the resident from bed to wheelchair using a Hoyer lift. The resident fell from the sling during the lifting process and landed on her back, slightly on her right side.
The nursing staff 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 left side of her head. X-rays were ordered for her right shoulder, right hip, and both knees.
But when federal inspectors reviewed the facility's abuse investigation in November, they discovered critical gaps in the documentation. The investigation summary claimed that interviews had been conducted with both nursing assistants who were present during the incident, as well as with the resident herself. None of those interviews could be found.
The resident who fell had been admitted to Monument Healthcare with multiple serious conditions including type 2 diabetes, a previous right femur fracture, major depressive disorder, respiratory failure, and hemiplegia. Her medical complexity made proper transfer procedures essential for her safety.
Federal regulations require nursing homes to thoroughly investigate all allegations of neglect, including incidents where residents are harmed during care. The investigation must document all staff and resident interviews conducted to determine whether neglect occurred.
The facility's own interdisciplinary team documented the fall three days later, but even basic facts were inconsistent. The nursing notes recorded the incident at 7:36 AM, while the fall review team documented it as occurring at 8:00 AM. The abuse investigation reported it to state authorities as happening at 1:45 PM on September 29 — a full week after the actual incident.
When inspectors interviewed the Director of Nursing on November 5, she acknowledged the investigation's deficiencies. She confirmed that the facility was required to report incidents to the State Survey Agency to identify problems including harm, neglect, and policy failures.
The Director of Nursing said she had conducted staff interviews during the investigation, inspected both the sling and the Hoyer lift equipment, and provided additional training to all nursing assistants on proper Hoyer lift use. The training emphasized inspecting the sling for damage and ensuring proper placement before each transfer.
Despite these claimed actions, the Director of Nursing admitted she would need to ask the previous administrator where the staff and resident interviews were located. She confirmed that the investigation documentation contained no copies of the interviews that were supposedly completed.
More significantly, she acknowledged that the investigation failed to examine whether the incident constituted neglect. Federal inspectors noted that "from the investigation it was not evident that they investigated the incident for possible neglect."
The missing documentation represents more than administrative oversight. Hoyer lift transfers require specific safety protocols, and falls during mechanical transfers can indicate equipment failure, improper technique, or inadequate staffing. Without interviewing the staff members who were present, investigators cannot determine what went wrong or whether the incident was preventable.
The resident's injuries extended beyond the initial complaints of knee and hip pain. The nursing assessment noted that she already had bruising on her right buttock that was being monitored before the fall, suggesting previous trauma or pressure injuries.
Neurological assessments were started immediately after the fall due to the head injury, and the resident was given ice and pain medications as needed. The facility ordered comprehensive imaging to evaluate potential fractures in multiple locations.
The investigation's timeline problems compound the documentation failures. The incident occurred on September 22, but the facility didn't report it to state authorities until September 29. Even then, the report incorrectly stated the time as 1:45 PM rather than the morning hours when it actually happened.
Such discrepancies raise questions about the facility's incident reporting systems and whether staff understand their obligations to document and investigate potential neglect cases promptly and thoroughly.
Federal inspectors found that Monument Healthcare's investigation violated requirements for responding appropriately to alleged violations. The citation carries a designation of "minimal harm or potential for actual harm," but the regulatory failure could mask more serious safety issues.
The case illustrates a broader problem in nursing home oversight. When facilities fail to conduct thorough investigations after residents are injured, they cannot identify systemic problems that might lead to future harm. They also cannot implement effective corrective measures or hold staff accountable for substandard care.
The Director of Nursing's admission that training was provided to all nursing assistants after the incident suggests the facility recognized problems with Hoyer lift procedures. But without documented interviews with the staff involved, there's no record of what specific errors occurred or whether they represented isolated mistakes or broader training deficiencies.
Monument Healthcare Bountiful serves residents with complex medical conditions who depend on staff to transfer them safely between beds, wheelchairs, and other locations throughout each day. Mechanical lifts like the Hoyer are essential equipment for residents who cannot bear their own weight during transfers.
When these transfers result in falls and fractures, nursing homes must investigate thoroughly to protect other vulnerable residents from similar incidents. The failure to document key interviews means Monument Healthcare cannot demonstrate that it took seriously its obligation to determine whether neglect occurred.
The resident who fell continues to live at the facility with her multiple medical conditions, including the consequences of whatever injuries she sustained during the September incident. The incomplete investigation means questions about her care may never be fully answered.
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 immediate jeopardy violations during a health inspection on November 6, 2025.
The resident fell from the sling during the lifting process and landed on her back, slightly on her right side.
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.