Monument Healthcare Bountiful
Monument Healthcare Bountiful in Bountiful, UT — inspection on November 6, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 out of 6 sampled residents, the facility did not ensure that all alleged violations involving neglect were reported no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
Specifically, a resident sustained a fall which resulted in a fracture during a one-person assisted transfer in a Hoyer lift and the State Survey Agency (SSA) and Adult Protective Services (APS) were not notified within 24 hours of the incident.
Resident identifier: 2.
Findings included:Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included type 2 diabetes mellitus, fracture of the right femur, abrasion of lower back, asthma, insomnia, major depressive disorder, obstructive sleep apnea, hemiplegia and hemiparesis, respiratory failure, hypertension, dysphagia, cognitive communication deficit, anxiety disorder, presence of urogenital implants, and bilateral cataracts.Resident 2's medical record was reviewed. On 9/25/25, the Interdisciplinary Team fall review documented that resident 2 sustained a fall from a Hoyer lift on 9/22/25 at 8:00 AM.The facility abuse investigation documented that the facility reported to the SSA that on 9/29/25 at 1:45 PM, Certified Nurse Assistant (CNA) 1 and CNA 2 were assisting resident 2 with a Hoyer lift transfer, and resident 2 fell out of sling upon lifting. It should be noted that the SSA was notified of the incident approximately seven days after the injury occurred.
Additionally, no documentation could be found to demonstrate that APS was notified of the incident. On 11/5/25 at 1:31 PM, an interview was conducted with the Director of Nursing (DON).
The DON stated that they were mandated to report to the SSA to identify problems such as harm, neglect, and policy failures.
The DON stated that the regulatory requirement for reporting to the state for suspected abuse or neglect was two hours.
The DON confirmed that from the investigation it was not evident that they investigated the incident for possible neglect.
The DON stated that they did not report to APS and she did not know why.
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/06/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Monument Healthcare Bountiful
460 West 2600 South Bountiful, UT 84010
SUMMARY STATEMENT OF DEFICIENCIES
Investigation Summary documented that an interview was conducted with resident 2, but no documentation could be found of the interview. On 11/5/25 at 1:31 PM, an interview was conducted with the Director of Nursing (DON).
The DON stated that they were mandated to report to the SSA to identify problems such as harm, neglect, and policy failures.
The DON stated that during the investigation they conducted staff interviews, inspected the sling and Hoyer, and then conducted training with every CNA on the Hoyer use which emphasized inspecting the sling each time for damage and proper placement.
The DON stated she would have to ask the previous Administrator where the interviews for the staff and resident were located.
The DON confirmed that from the investigation it was not evident that they investigated the incident for possible neglect and that the investigation documentation did not contain copies of the interviews that were completed.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/06/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Monument Healthcare Bountiful
460 West 2600 South Bountiful, UT 84010
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
DON stated that if the latches were missing that would be concerning because it was open, and it posed a risk of malfunction and harm.
The DON stated that without the safety latches the lifts were not in good working condition and the slings could potentially slip off.
Review of the Viking XL Mobile Lift Instruction Guide documented under safety to ensure the latches are intact; missing or damaged latches must always be replaced; .
The guide further documented under Installation of Latches, After installation, ensure that the spring loaded latches is taut against the sling bar and moves freely in the sling bar hook.
Review of the facility policy and procedure for Positioning/Moving: Lifting Machine, Using a Mechanical documented under general guidelines that at least two nursing assistants were needed to safely move a resident with a mechanical lift.
The policy documented under procedure steps to Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition.
The policy further documented, Attach sling straps to sling bar, according to manufacturer's instructions. a.
Make sure the sling is securely attached to the clips and that it is properly balanced. b.
Check to make sure the resident's head, neck and back are supported. c.
Before resident is lifted, double check the security of the sling attachment. d.
Examine all hooks, clips or fasteners. e.
Check the stability of the straps. f.
Ensure that the sling bar is securely attached and sound.
The policy was last revised on February 1, 2024.
Facility ID: