Monument Healthcare American Fork

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, it was determined the facility did not ensure that residents who use psychotropic drugs received a gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically for 1 out of 19 sampled residents, a resident did not have an attempted GDR for psychotropic medications. Resident identifier: 20.Findings included: 1. Resident 20 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses which included, schizoaffective disorder bipolar type and depression.Resident 20's medical

record was reviewed on 9/2/25-9/4/25.On 9/2/25 at 9:16 AM, 10:02 AM, and 12:17 PM observations were made of resident 20 sleeping in bed. A physician's order dated 3/14/23, documented clozapine oral tablet (Clozapine) Give 100 mg one time a day for a diagnosis of schizoaffective disorder, bipolar type.A physician's order dated 3/14/23, documented clozapine oral tablet (Clozapine) Give 150 mg one time a day for a diagnosis of schizoaffective disorder, bipolar type.A physician documented clinical contraindication was unable to be located and the medication had not received the appropriate GDR. On 9/4/25 at 8:39 AM,

an interview was conducted with the Director of Nursing (DON). The DON stated that psychotropic meetings were held on the third Wednesday of every month and that resident's medications were reviewed at least quarterly. The DON stated that if a resident starts a GDR then they are reviewed in the next month's psychotropic meeting. The DON stated that resident 20 had been on clozapine since March of 2023 and he could not find if a GDR had been done.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare American Fork

350 East 300 North American Fork, UT 84003

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, it was determined that for 1 of 19 sampled residents, that the facility did not ensure that a resident was given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including eating. Specifically, a resident did not receive assistance with eating his meals. Resident Identifier: 1

Residents Affected - Few

Resident 1 was initially admitted [DATE REDACTED], readmitted [DATE REDACTED] with diagnoses including legal blindness, cerebral infarction, tremor, need for assistance with personal care, dysphagia following cerebral infarction, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.

Resident 1's medical record was reviewed from 9/2/25 through 9/4/25.

Resident 1's Care Plan was reviewed. The Care Plan documented that Resident 1 had an activities of daily living deficit related to his hemiplegia, difficulty moving, and his loss of vision. The Care Plan documented that Resident 1 needed setup and cleanup assistance from up to 1 staff member when eating.

On 9/4/25 at 7:57 AM, an observation was made of CNA 1 who dropped off resident 1's breakfast tray and left the room.

On 9/4/25 at 9:00 AM, an interview was conducted with the Lead [NAME] (LC). The LC stated that Resident 1 is blind, that she is not sure if he feeds himself or not, and that he prefers to have his meat cut up.

On 9/4/25 at 9:03 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that Resident 1 uses a divided plate, that he can feed himself, and that the facility sometimes has staff assist him with eating.

On 9/3/25 at 1:19 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 1 was blind and had been on a steady decline and could not see what was on his plate when served meals. CNA 1 stated that he had assisted resident 1 with eating for the past couple of weeks. CNA 1 stated that he had noticed that resident 1 was not eating his meals and took it upon himself to assist him with eating.

On 9/4/25 at 9:09 AM, an interview was conducted with CNA 2. CNA 2 stated that the facility usually has someone sit with Resident 1 while he eats. CNA 2 stated that sometimes Resident 1 is a total assist for feeding and sometimes he is a supervised assist. CNA 2 stated that the amount of assistance Resident 1 needs depends on how the resident feels that day.

On 9/4/25 at 9:14 AM, an interview was conducted with the Registered Nurse (RN). RN stated that Resident 1 is legally blind. RN 1 stated that if Resident 1 is in a good mood, he will allow more staff to assist him more with his activities of daily living.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet