Monument Healthcare Bountiful

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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 REDACTED] and re-admitted

on [DATE REDACTED] 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

(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

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare Bountiful

460 West 2600 South Bountiful, UT 84010

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 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

**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, that in response to allegations of neglect the facility must have evidence that all alleged violations were thoroughly investigated. Specifically, a resident sustained a fall which resulted in a fracture during a one-person assisted transfer in a Hoyer lift and the facility abuse investigation did not contain documentation of all staff and resident interviews that were conducted to rule out neglect. Additionally, the abuse investigation incorrectly documented the date of the incident.Findings included:Resident 2 was admitted to the facility on [DATE REDACTED] and re-admitted on [DATE REDACTED] 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 9/22/25 at 7:36 AM, the nursing note documented, RNA [Restorative Nurse Aide] alerted nurse that resident had fallen from the Hoyer lift during transfer from bed to wheelchair. Nurse rushed into room to assess resident. Resident was found on her back slightly on R [right] side. Nurse evaluated resident for step off or fx [fracture] limbs and extremities and spine felt intact with no step off felt or unusual movement and pain to joints or extremities. Resident did c/o [complaint of] pain to L [left] knee and R hip.

Goose egg to back of L side head found approximately 30mins [minutes] [sic] after fall.Nurse evaluated resident for injuries, broken bones, bruising and pain. No new injuries noted but resident did c/o pain to R shoulder, R hip, and L knee. Bruising to R buttock was already present and being monitored before fall.

Nurse notified On-call [provider company name omitted] provider [name omitted]. Neworders [sic] received from provider for x-rays to R shoulder, R hip, and bilateral knee 2 views, and to start neuro's [neurological assessment] and to apply ice PRN [as needed] and PRN pain medications as applicable. Neuros started.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 State Survey Agency (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. The investigation documentation did not contain interviews with CNA 1 or CNA 2 regarding the incident. Additionally, the 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.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet

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

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare Bountiful

460 West 2600 South Bountiful, UT 84010

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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

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.

Event ID:

Facility ID:

If continuation sheet