North Canyon Care Center

F-F689 has been removed.

Summary of Action Taken:

Resident 12:

-Resident had a skin assessment-no injury noted

-Attending physician was notified

- Resident was reassessed for smoking safety by the RNC/Nurse Manager, which included a return demonstration of smoking safety

-Care plan reviewed and updated to supervised smoking and a smoking apron

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 -Resident room was checked for smoking material-any smoking material found was removed and will be stored by nursing Level of Harm - Immediate jeopardy to resident health or -Resident was educated on the Smoking Policy, which included storage of smoking material safety Resident 293: Residents Affected - Some -Resident was reassessed for smoking safety by the RNC/Nurse Manager, which included return demonstration of smoking safety

-Care plan was developed based on smoking safety screen

-Resident room was checked for smoking material-any smoking material found was removed and will be stored by nursing

-Resident was educated on the Smoking Policy, which included storage of smoking material

Resident 23:

-Resident was reassessed for smoking safety by the RNC/Nurse Manager, which included a return demonstration of smoking safety

-Care plan was reviewed and updated based on smoking safety screen

-Resident room was checked for smoking material-any smoking material found was removed and will be stored by nursing

-Resident was educated on the Smoking Policy, which included storage of smoking material

Resident 5:

-Resident was reassessed for smoking safety by the RNC/Nurse Manager, which included a return demonstration of smoking safety

-Care plan was reviewed and updated based on smoking safety screen

-Resident room was checked for smoking material-any smoking material found was removed and will be stored by nursing

-Resident was educated on the Smoking Policy, which included storage of smoking material

Other Residents at Potential Risk:

-All residents that smoke were reassessed for smoking safety by the RNC and/or nurse manager, which included a return demonstration of smoking safety

-Care plans were reviewed and updated as applicable

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 -All residents that smoke were assessed for smoking injuries

Level of Harm - Immediate -The smoking list was updated to reflect all smokers and level of supervision jeopardy to resident health or safety -Resident rooms were checked for smoking material-any smoking material found was removed and to be stored by nursing Residents Affected - Some -Residents that smoke were reeducated on the smoking policy and storage of smoking material

-All residents who smoke will be assessed for smoking safety upon admission/readmission, quarterly and with a change of condition, this assessment will include a return demonstration of smoking safety

-Resident will be education upon admission/readmission of the facility's smoking policy and storage of smoking material

Systemic Changes and Education:

-Administrator, DON, and RNC reviewed smoking policy

-Administrator, DON were educated by RNC regarding smoking policy

-Specifically on smoking supervision, updated smoking list and level of supervision and storage of smoking material

-Administrator, DON/designee will complete Smoking education with all staff, including agency

-Specifically on smoking supervision, updated smoking list and level of supervision and storage of smoking material

-All current staff, including agency have been educated

-All staff, including agency will be educated prior to the start of their next shift

-Administrator/DON/designee will complete education with facility nurses on how to complete a Smoking Screen specifically that the assessment includes a return demonstration of smoking safety

Monitoring and Quality Improvement Measure:

-The administrator/designee will conduct 5 random resident observations on resident that smoke weekly x 4 weeks and then monthly thereafter x3 months to ensure the Smoking Policy have been followed specifically

on smoking supervision, updated smoking list and level of supervision and storage of smoking material

-The DON/designee will review smoking screen assessments weekly x 4 weeks and then monthly thereafter x3 months to ensure the assessment matches the resident

-Medical Director was informed of the incident and QAA Review & Recommendations

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 -Results will be reported to the QAA committee for monitoring and follow-up

Level of Harm - Immediate -The Administrator is responsible for substantial compliance of this Plan of Action jeopardy to resident health or safety The facility alleges the immediacy with the deficient practice has been removed on January 29, 2025 by 4:30 PM. Residents Affected - Some

The survey staff confirmed the removal of the IJ on 1/30/25 at 8:53 AM.

IMMEDIATE JEOPARDY

On 1/27/25, the facility provided a list of residents that were currently smoking. The list included residents: 5, 12, 23, 27, 30, and 34. According to the list resident 34 needed assistance getting outside and the others were independent with smoking.

1. Resident 12 was admitted to the facility on [DATE REDACTED] with diagnoses that included schizophrenia, chronic obstructive pulmonary disease, type 2 diabetes, follicular lymphoma, panlobular emphysema, and lymphocytopenia.

On 1/27/25 at 10:55 AM, an observation was made of resident 12 in his room. Resident 12 was taking cigarettes out of his night stand in preparation to go and smoke. An interview was conducted with resident 12. Resident 12 stated he was allowed to keep his smoking materials in his room and he kept his lighter in

the pocket of his jacket that he wore all the time. Resident 12's left hand was observed to be moving during

the interview.

On 1/28/25 at 11:46 AM, an observation was made of resident 12 smoking a cigarette outside near the designated smoking area. Resident 12 was observed smoking independently with no adaptive or protective equipment. Resident 12 was observed to have the cigarette in his right hand. Resident 12 was observed to have abrupt, jerking movements with his right hand. Resident 12 was observed to have a burn hole in his pants. Ash was observed to be falling on the resident's lap. Resident 12's plaid pajama bottoms were observed to have a small hole on one of the legs. An interview was conducted with resident 12 who stated

he did not need to be using a smoking apron. At 12:28 PM, resident 12 was smoking a cigarette in the smoking area. Resident 12 was holding his cigarette in his left hand, and his left hand was observed to have

a abrupt movements with his left arm as he lifted the cigarette to his mouth and back down again. At 12:30 PM, Resident 12 was observed to dropped his cigarette on to the ground. Resident 12 leaned over and picked up the cigarette and continued smoking it.

On 1/28/25 at 5:14 PM, an observation was made of resident 12. Resident 12 was observed to be in the smoking area with Licensed Practical Nurse (LPN) 1. Resident 12 was observed to be smoking apron or assistive devices.

Resident 12's medical record was reviewed between 1/27/25 and 2/6/25.

On 1/21/25, a smoking assessment was completed by LPN 1.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 Resident 12's care plan initiated on 1/23/24 revealed, [Resident 12] is a smoker and chooses to smoke while at the facility. The goal was, [Resident 12] will not suffer injury from unsafe smoking practices through the Level of Harm - Immediate review date. Interventions initiated on 1/24/24 included, Cigarettes (or other smoking materials) should be jeopardy to resident health or stored in a locked box by the nurses station. [Resident 12] has the key to his box. Encourage compliance.; safety Instruct resident about the facility policy on smoking: locations, times, safety concerns; Notify charge nurse immediately if it is suspected resident has violated facility smoking policy; Observe clothing and skin for signs Residents Affected - Some of cigarette burns. Notify LN [Licensed Nurse] immediately if present; and The resident can smoke UNSUPERVISED.

On 1/28/25 at 3:11 PM, an interview was conducted with LPN 1 who stated he completed smoking assessments on residents when they were admitted to the facility. LPN 1 stated he had a score that he used when evaluating resident for smoking to determine if they could smoke independently or not. LPN 1 stated

he had not noticed anything about resident 12 that he would consider unsafe to smoke independently. LPN 1 stated if there was information that was concerning he would notify the Lead Certified Nursing Assistant (CNA) so she could let the CNA's know. LPN 1 stated his communication with CNA's was verbal. It should be noted that LPN 1 reviewed the smoking assessment he completed on 1/21/25 and stated there was no score

on the assessment.

On 1/30/25 at 9:27 AM, an interview was conducted with resident 12 who stated he had been educated about the smoking policy by administration earlier that morning and was now wearing a smoking apron while smoking.

2. Resident 34 was admitted to the facility on [DATE REDACTED] with diagnoses that included non-traumatic intracerebral hemorrhage, hemiplegia and hemiparesis, heredity and idiopathic neuropathy, homonymous bilateral field deficits, reduced mobility, depressive episodes, chronic kidney disease, and pre-diabetes.

On 1/27/25 at 11:13 AM, an interview was conducted with with resident 34 who stated he was not smoking.

Resident 34's medical records were reviewed between 1/17/25 and 2/6/25.

An admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed resident 34 had a Brief

Interview for Mental Status (BIMS) score of 13 indicating resident 34 was cognitively intact. Additionally, the MDS admission assessment included, Current Tobacco Use: NO.

It should be noted an admission smoking assessment could not be found in resident 34's medical record.

Resident 34's care plan dated 9/2/24 revealed, [Resident 34] is a smoker and chooses to smoke while at the facility. The goal was, [Resident 34] will not suffer injury from unsafe smoking/vaping practices through the

review date and [resident 34] will not smoke without supervision through the review date. Interventions included, Cigarettes (or other smoking materials) to be stored at the nurses desk; Instruct resident about the facility policy on smoking: locations, times, safety concerns; [Resident 34] needs to be supervised (by staff or family) when he goes outside to smoke. He needs staff to push him outside; and Observe clothing and skin for signs of cigarette burns. Notify LN immediately if present.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 On 8/2/24, a provider progress note revealed, Chief complaint: Admit .Social History: .From chart: Substance abuse, tobacco use, requesting nicotine patch 7 mg [milligrams] daily. Level of Harm - Immediate jeopardy to resident health or On 1/7/25, a provider progress note revealed, Chief complaint: Fall .Social History: .From chart: Substance safety abuse, tobacco use, requesting nicotine patch 7 mg daily.

Residents Affected - Some 3. Resident 5 was admitted to the facility on [DATE REDACTED] with diagnoses which included, paraplegia, pressure ulcers of the right and left buttocks, pressure ulcer of sacral region, type 2 diabetes, and unspecified symptoms and signs involving cognitive functions and awareness.

Resident 5's medical record was reviewed 1/27/25-2/6/25.

On 1/8/25, a smoking evaluation was completed on resident 5. The smoking evaluation revealed the following:

a. The resident had a history of hiding their smoking materials or activities from staff.

b. The resident had a history of noncompliance with the facilities smoking policy.

c. The resident was unable to retrieve a cigarette if it were dropped.

d. The resident used medications that could cause drowsiness.

It should be noted that approximately 21 days had passed after admission before resident 5 was assessed for smoking safety and did not reveal if resident 5 required supervision while smoking or could be an independent smoker

Resident 5's care plan initiated on 1/8/25 revealed that resident 5's smoking supplies should be stored in a lock box near the nurse's station. Resident 5 had a key to the lock box and compliance should be encouraged.

On 1/28/25 at 12:31 PM, an observation was made of resident 5 and resident 23 outside in the resident smoking area. Resident 5 was observed to light a cigarette in her mouth and then pass the lit cigarette to resident 23 who then placed the cigarette into her mouth. Resident 5 and resident 23 were observed to continue to smoke the lit cigarette by passing it back and forth between them.

On 1/28/25 at 4:00 PM, an interview was conducted with resident 5. Resident 5 stated she was able to keep her cigarettes and lighter in her room and did not ask staff for them.

4. Resident 293 was admitted to the facility on [DATE REDACTED] with diagnoses which included displaced intertrochanteric fracture of left femur, other toxic encephalopathy, major depressive disorder, tobacco use, muscle weakness, and need for assistance with personal care.

Resident 293's medical record was reviewed 1/27/25-2/6/25.

A review of resident 293's nursing admission evaluation dated 1/15/25, documented that resident 293 used tobacco, alcohol, or drugs and was a current smoker. It should be noted a smoking evaluation was not performed on resident 293.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 On 1/27/25 at 9:50 AM, an interview was conducted with resident 293. Resident 293 stated he was a smoker and smoked around 2-3 cigarettes a day. Level of Harm - Immediate jeopardy to resident health or On 1/28/25 at 3:01 PM, an interview was conducted with CNA 2. CNA 2 stated resident 293 would smoke safety outside with his son. CNA 2 stated residents were free to smoke whenever they wanted to. CNA 2 stated cigarettes and lighters could be kept in the resident's rooms. Residents Affected - Some 5. Resident 23 was admitted to the facility on [DATE REDACTED] with diagnoses which included bipolar disorder with psychotic features, dementia, convulsions, cognitive communication deficit, muscle weakness and need for assistance with personal care.

An MDS dated [DATE REDACTED] revealed resident 23 had a BIMS score of 10 which indicated moderate cognitive impairment.

A smoking screening evaluation dated 1/1/25 revealed resident 23 had problems with communicating effectively with others, was unable to use a fire extinguisher to extinguish a fire as a result of smoking, and used medications that could cause drowsiness. It was determined, however, that resident 23 was able to smoke unsupervised and staff should notify the charge nurse immediately if it was suspected the resident had violated facility smoking policy.

A care plan initiated 1/18/23 and updated on 9/16/24 documented that resident 23 was a smoker and stated at that time she wanted to quit smoking and use Nicotine patches but always went back to smoking. The goal was that resident 23 would not suffer injury from unsafe smoking practices through the review date. The care plan indicated that resident 23's smoking supplies should be stored in a lock box near the nurses station and resident 23 had the key. The care plan further revealed resident 23 could smoke unsupervised.

Another care plan dated 1/31/24 revealed that resident 23 asked other residents for cigarettes. The goal was resident 23 would smoke her own cigarettes. Interventions included recreation staff had offered to buy cigarettes for resident 23 on scheduled shopping trips and she was reminded it was not appropriate for her to ask others for her cigarettes.

A Social Services Quarterly & Annual Note dated 4/2/24 at 12:13 PM revealed resident 23's BIMS was 9.

The note further revealed . Resident often asks other smokers for cigarettes and at times gets upset when

the other resident is unable to give her a cigarette. Other residents have mentioned that she will beg them for their cigarettes and tell them they are lucky they can afford them.

On 1/28/25 at 3:12 PM, an interview was conducted with CNA 1. CNA 1 stated residents could go out on their own to smoke and did not need staff to accompany them. CNA 1 stated staff could watch the residents smoking through the window in the family room. CNA 1 stated residents should keep their smoking supplies

in the locked boxes near the nurses station. CNA 1 stated nurses would gather the resident's smoking supplies and lock them in the locked boxes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 On 1/28/25 at 3:25 PM, an interview was conducted with the DON who stated the Unit Manager (UM) was typically the person who completed smoking assessments on the residents and she would be the person to Level of Harm - Immediate ask about how the smoking screening determined the resident's ability to smoke independently. The DON jeopardy to resident health or stated the smoking assessments were only done quarterly. The DON stated resident 12 had a lock box on safety the wall by the nurses station and that was where he kept his smoking materials. The DON stated he did not have any concerns about resident 12 smoking unsupervised or unsafely. The DON stated resident 12 was a Residents Affected - Some fast smoker. The DON stated if he witnessed resident 12 dropping ash on himself he would not consider him safe to smoke independently.

On 1/28/25 at 3:27 PM, an interview was conducted with CNA 1. CNA 1 stated there used to be set times for smoking, but now residents were able to smoke when they wanted to. CNA 1 stated there was a smoke shack that residents smoked under and staff were able to see them. CNA 1 stated resident 34 required supervision when smoking. CNA 1 stated staff had to go outside to the smoke shack with him while he smoked. CNA 1 stated no residents needed any smoking equipment or devices. CNA 1 stated if she was seeing a resident that was unsafe smoking, she would tell her supervisor nurse or the DON. CNA 1 stated

she would write up a statement about it. CNA 1 stated there were no observations of burn holes in anyone's clothing. CNA 1 stated residents were very careful and no one had burned clothing because the residents who smoke were really with it.

On 1/28/25 at 4:04 PM, an additional interview was conducted with the DON who stated he had observed resident 12 with a burn hole in his pants and involuntary movement. The DON stated resident 12 was being placed on supervised smoking going forward. The DON stated he had not witnessed involuntary movements or burn holes in resident 12's clothing until today.

On 1/28/25 at 4:37 PM, an interview was conducted with RN 4. RN 4 stated residents were screened for their smoking abilities upon admission. RN 4 stated she was unaware of any supervised smokers in the facility. RN 4 stated none of the residents in the facility showed a need to use a smoking apron or other device. RN 4 stated resident 5 was fine to smoke independently. RN 4 stated she was unaware that resident 293 smoked. RN 4 stated she did not monitor the residents while they smoked. RN 4 stated the residents should put their smoking supplies in the locked boxes. RN 4 stated she was unaware of any residents that share cigarettes or did not follow the smoking policy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 On 1/28/25 at 4:40 PM, an follow up interview was conducted with the DON. The DON stated if resident wanted to smoke, then nurses completed a smoking evaluation. The DON stated the evaluation included Level of Harm - Immediate how many times a day a resident smokes, what time of day, cognitive loss, visual deficits, problems with jeopardy to resident health or communication, dexterity problems, disposing of ashes and cigarette, hiding smoking material, history of safety non-compliance, smoking in non-designated area, able to pick up, extinguish a fire, use supplemental oxygen, no tremors, drowsiness, burns, and can the resident light his or her own cigarettes. The DON stated Residents Affected - Some based on evaluation resident 12 seemed to be able to smoke independently. The DON stated all smokers were A&O x 3-4 (alert and oriented to person, place, time and situation). The DON stated residents were also able to light and extinguish cigarettes. The DON stated if there were physical signs of burns, which was pointed out today, then the resident was put on a supervised smoking schedule. The DON stated resident 12 moved his hand fast when he was smoking and moved it away from his body so there was no concern with him burning himself. The DON stated after staff assessed resident 12, he now needed a smoking apron. The DON stated resident 12 was alert and oriented x 3-4 with some forgetfulness. The DON stated resident 5, resident 30, resident 27, and resident 12 smoked. The DON stated he was not sure if resident 23 was currently smoking. The DON stated she had a history of smoking but thought she was on a nicotine patch and had stopped smoking. The DON stated if resident 23 started smoking again then staff needed to know.

The DON stated resident 23 probably started smoking when resident 5 returned to the facility. The DON stated the Unit Manager should be aware of who was smoking. The DON stated nurses needed to go out and physically watch each resident smoke when completing the smoking evaluation.The DON stated CNA's would know who smoked by the Kardex system. The DON stated all residents could keep their lighters and cigarettes. The DON stated there was a lock box by the nurses station to store smoking materials. The DON stated residents who smoked had access to the lockers. The DON stated resident 12 had a key to the locker for his smoking material. The DON stated all residents should be storing their smoking materials in the lockers.

On 1/28/25 at 4:40 PM, a follow up interview was conducted with LPN 1 who stated the process for determining if a resident was safe to smoke was to make sure the resident had a smoking assessment. LPN 1 stated if they did not, he would complete one. LPN 1 stated he used his professional judgement when completing resident 12's smoking assessment. LPN 1 stated if anything seemed hazardous he would determine the resident was not safe to smoke independently. LPN 1 stated if residents were dropping stuff

he would determine that smoking devices were needed. LPN 1 stated the reason he completed the smoking assessment on resident 12 was it popped up in resident 12's medical chart that day. LPN 1 stated he did not observe resident 12 when completing his smoking assessment and filling out the screening form. LPN 1 stated there was a lock box near the nurses station where residents kept their smoking materials. LPN 1 stated resident 12's smoking materials were in the narcotics drawer and had his name on them. LPN 1 stated he thought resident 12's smoking materials were in his lock box before being put in the narcotics drawer.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 On 1/28/25 at 4:59 PM, an interview was conducted with the Administrator (ADM) who stated all residents who smoked were independent. The ADM stated if a smoking resident was showing signs of doing Level of Harm - Immediate something that would make them unsafe they should bring it up with the DON. The ADM stated actions that jeopardy to resident health or would be considered unsafe would be not being able to hold a cigarette, not being stable to hold a cigarette, safety cognitive impairment, inability to make choices, inability to perform Activities of Daily Living (ADL)'s and take care of themselves, or needing extra assistance. The ADM stated he did not know if staff members went out Residents Affected - Some to the smoking area to ensure residents were smoking safely. The ADM stated he was unsure where residents were keeping their smoking materials. The ADM stated residents could request a smoking apron if

they wanted one, but most residents did not want to use a smoking apron, they just go out and smoke. The ADM stated when a resident was admitted with a history of smoking, staff went over the smoking policy with

the resident. The ADM stated he did not know resident 12 very well and had not observed any type of uncontrolled movement when talking with resident 12. The ADM stated he did not know if there was a particular staff member who completed the smoking assessments.

On 1/28/25 at 5:08 PM, an interview was conducted with the DON who stated staff were aware of which residents smoked by looking at the resident's KARDEX, and the care plan. The DON stated smoking assessments were completed on every resident whether or not they were smokers.

On 1/29/25 at 9:00 AM, an interview was conducted with CNA 3 who stated she had not noticed resident 12 to have any involuntary movements. CNA 3 stated she had not observed any burn holes on resident 12's clothing. CNA 3 stated resident 12 was a partial to substantial assist depending on the day or time of day. CNA 3 stated resident 12 would ask for help if he needed anything. CNA 3 stated a resident holding a cigarette for too long or burning themselves would be a concern. CNA 3 stated if she observed a safety concern while a resident was smoking she would notify the nurse and go and supervise the resident or have another staff member supervise the resident.

On 1/29/25 at 9:11 AM, an interview was conducted with the Unit Manager (UM) who stated she was the staff member who usually completed the smoking screens. The UM stated when completing the screenings

she would watch the resident smoke to ensure they could light the cigarette safely, put it out safely, smoke safely in the designated area. The UM stated she looked for tremors and involuntary movements when conducting the assessments. The UM stated smoking evaluations were completed on admission, quarterly and annually. The UM stated the current smoking evaluation did not have an area to mark if the resident was not a smoker. The UM stated residents were keeping their smoking materials on their person, however the facility changed that yesterday. The UM stated now all residents are keeping their smoking materials at the nurse's station. The UM stated a staff member had to go out with residents who required supervision, and it could be a floor staff member, a clinical staff member or someone from the management team. The UM stated smoking times were posted at the nurse's station and in the CNA break room.

On 1/29/25 at 11:12 AM, an interview was conducted with LPN 2. LPN 2 stated resident 23 was a smoker and did not require supervision. LPN 2 stated smoking materials were stored at the nurses station somewhere. LPN 2 stated resident 23 would not be able to keep her smoking material.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 On 1/29/25 at 11:14 AM, an interview was conducted with RN 1. RN 1 stated resident 23 smoked and was able to unsupervised. RN 1 stated since last night all smoking materials were kept at the nurses station. RN Level of Harm - Immediate 1 stated prior to last night residents were able to keep their smoking material including resident 23. RN 1 jeopardy to resident health or stated there were lock boxes at the nurses station for resident to keep their smoking material but residents safety kept losing their keys.

Residents Affected - Some The smoking policy and procedures revised on 3/2019 provided upon entrance was reviewed and revealed

the following:

Physical Environment Smoking- Supervised Smokers .

Purpose: To provide a safe environment for residents.

Policy: The facility shall establish and maintain safe practices in an effort to keep residents safe while smoking.

Guidelines:

1. Smoking will occur in designated areas only. The designated smoking area will be placed in a location compliant with local and state specific regulations.

2. The facility will furnish the designated smoking area with a fire extinguisher and proper receptacle for extinguishing smoking materials. Smoking blankets or aprons will be furnished for residents who are assessed to require a smoking blanket or apron.

3. Residents who wish to smoke will be assessed for smoking safety by nursing.

4. Smoking assessments will be completed on admission, quarterly, with significant change of condition and as needed for residents who wish to smoke. Smoking assessment will include a return demonstration of ability to safely manage smoking paraphernalia.

5. Residents who smoke will be supervised by staff members while smoking. Smoking will occur at designated smoking times.

6. Smoking paraphernalia will be managed by nursing staff and will be made available at designated smoking times.

7. Residents requiring continuous oxygen administration will require supervision while smoking and will smoke during desgnated smoking times. Oxygen tanks and concentrators will be placed outside of desginated smoking areas.

8. Pipes, cigars, electronic cigarettes and vapes are considered smoking paraphernalia and their usage is subject to theses same guidelines.

48709

Falls

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 1. Resident 18 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses which included displaced dens fracture, end stage renal disease, dementia, hypertension, and type 2 diabetes Level of Harm - Immediate mellitus. jeopardy to resident health or safety On 1/28/25 at 2:17 PM, an observation was made of resident 18 in her room sleeping in bed wearing a neck collar, the bed was in a low position, a fall mat was on the right side of the bed with her wheelchair positioned Residents Affected - Some on the fall mat, and there was no call light observed within reach of the resident.

On 1/28/25 at 2:24 PM, an interview was conducted with CNA 2 in resident 18's room. CNA 2 stated resident 18's call light was hanging up on the wall and that she was a fall risk. CNA 2 stated resident 18 needed assistance to get up. During the interview, the resident was observed to be attempting to get out of bed on

the left side of the bed where there was no fall mat.

Resident 18's medical record was reviewed 1/27/25 through 2/6/25.

A Quarterly MDS dated [DATE REDACTED] indicated a BIMS score of 2. A BIMS score between 0-7 indicated severe cognitive impairment.

A Nursing Note dated 9/18/24 at 5:39 PM indicated, pt [patient] FOF [found on floor] on her fall mat by CNA at 400 [4:00 AM] . There was no updated intervention made to the care plan.

A Nursing Note dated 10/6/24 at 3:30 AM indicated, While rounding on the resident the resident was found

on the floor next to her bed. There was no updated intervention made to the care plan.

A Nursing Note dated 1/3/25 at 4:06 PM indicated, Pt found by CNA @15:45 [at 3:45 PM] on the floor next to her bed. Pt reported trying to get up to go to the bathroom but slide [sic] out of bed .

The care plan Intervention initiated on 1/3/25 indicated, Education to be provided about alarm use.

A Nursing Note dated 1/6/25 at 4:10 PM indicated, Pt fof next to bed on fall matt laying on right side mostly face down, bed was in lowest position, pull tab alarm in place and functioning. Alarm still attached to Pt and repositioning bar on bed. Head to toe assessment done, Pt has small skin tear to right forearm. Cleansed and dressed. Pt c/o [complains of] pain to both hands. Aid [NAME] [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50200 Residents Affected - Few Based on observation, interview and record the review it was determined, for 4 of 33 sample residents, that

the facility failed to ensure that residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to maintain or restore continence to the extent possible. Specifically, 2 residents had a delay in treatment for urinary tract infections (UTI) with 1 requiring another medication to manage symptoms. In addition, 2 residents were not placed on a bowel and bladder training program despite staff assessment of appropriateness. Resident identifiers: 6, 25, 31, and 35.

Findings include:

HARM

1. Resident 35 was admitted to the facility on [DATE REDACTED] with diagnoses which included wedge compression fracture of fifth lumbar vertebra, spinal stenosis, radiculopathy, aortocoronary bypass graft, type 2 diabetes mellitus, and hypertension.

A review of resident 35's progress notes revealed:

a. On 10/24/24 at 4:36 PM, a nursing note documented, pt [patient] reports [NAME] [sic] on urination. provider notified. new order received to collect UA [urinalysis] with c&s [culture and sensitivity]. pt is her own POA [power of attorney] and notified of new order. pt verbalizes agreement and understanding.

b. On 10/28/24 at 10:32 PM, a nursing note documented, preliminary UA results received. result positive. awaiting culture results. placed in dr's [doctor's] folder.

c. On 10/29/24 at 12:22 PM, a nursing note documented, Results received from UA collected 10/24. NP [nurse practitioner] [name redacted] gave order for Pyridium 100 mg [milligrams] po [by mouth] TID [three times a day] x [times] 3 days. Waiting for c&s. Pt made aware

d. On 10/31/24 at 1:31 PM, a nursing note documented, MD [medical doctor] new orders for Nitrofurantoin 100mg [sic] 1 po BID [two times a day] x 3 days for UTI [urinary tract infection]. Patient notified. Orders noted.

e. On 11/1/24 at 9:15 PM, a nursing note documented, The resident is on alert charting for UTI taking PO macrobid. The resident is still c/o [complaining of] burning when urinating .

f. On 11/2/24 at 9:09 AM, a nursing note documented, pt continues on PO ABX [antibiotic] therapy for UTI. pt. reports some urinary symptoms remain, but that burning has lessened since starting ABX therapy.

g. On 11/3/24 at 9:54 PM, a nursing note documented, .The resident is c/o pain/burning when urinating. Provider notified .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0690 h. On 11/4/24 at 12:12 AM, a nursing note documented, Urine culture results collected on 10/24/24 at 1730 [5:30 PM] Result: aerococcus species . Susceptible to: ceftriaxone, linezolid, PCN [penicillin] ,vanco Level of Harm - Actual harm [vancomycin], No interpretation to: daptomycin, doxycycline. Intermediate to: levofloxacin. provider notified

Residents Affected - Few i. On 11/6/24 at 6:25 PM, a nursing note documented, new order received from provider: amoxicillin 500 mg po TID X 3 days. pt is her own POA and notified of new order. pt verbalizes agreement and understanding.

It should be noted that Nitrofurantoin was not an antibiotic susceptible to treat resident 38's urinary tract infection.

On 2/4/25 at 1:02 PM, an interview was conducted with the Unit Manager (UM). The UM stated she was the Infection Preventionist for the facility. The UM stated resident 38 had chronic UTI's and the doctor wanted to wait for the culture results before starting antibiotics. The UM stated that urine culture results took 2 to 5 days. The UM stated if results were not back from the lab in that timeframe she would contact the lab and document in the resident's medical record. The UM stated resident 38 continued to have urinary symptoms and was given pyridium on 10/29/24. The UM stated she did not call the lab to get urine culture results for resident 38 and the facility did not receive the results until 11/3/24.

On 2/5/25 at 11:29 AM, an interview was conducted with Regional Nurse Consultant (RNC) 1. RNC 1 stated urine cultures took a minimum of 48 hours to grow bacteria. RNC 1 stated if a resident continued to have urinary symptoms she would expect the nursing staff to communicate with the physician and get orders.

On 2/5/25 at 1:37 PM, an interview was conducted with RNC 2. RNC 2 stated the nurse practitioner was notified of resident 38's urinary pain on 10/24/24. RNC 2 stated resident 38 was reassessed on 10/29/24 and continued to have urinary pain so pyridium was prescribed. RNC 2 stated the urine culture took longer than usual, and staff was expected to contact the lab to determine the cause of the delay. RNC 2 stated there was no documentation to verify if the lab was contacted or not.

30563

Potential for Harm

2. Resident 6 was admitted to the facility on [DATE REDACTED] with diagnoses which included type 2 diabetes mellitus, urine retention, major depressive disorder, generalized anxiety, and muscle weakness.

Resident 6's medical record was reviewed on 1/27/25 through 2/6/25.

A care plan revealed that resident 6 was incontinent with bladder. The goal was that resident 6 will be free from complications related to incontinence. The interventions were to check for incontinence at regular intervals and assist with urinal use at residents request.

A nursing progress note dated 12/19/24 at 3:18 PM, revealed, Resident c/o burning while urinating. [name removed] NP in facility and gave orders to obtain a UA with C&S .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0690 A physician's order dated 12/19/24, revealed to obtain UA with C&S one time only for burning with urination.

Level of Harm - Actual harm A nursing progress note dated 12/27/24 at 1:23 PM, revealed, Residents UA with C&S test results did not come back from 12/18 [24] collection. This nurse called on call [name removed] NP [name removed]. [name Residents Affected - Few removed] NP gave orders to collect another UA with C&S. Resident notified.

A physician's order dated 12/27/24, revealed to obtain UA with C&S one time only for increased white blood cells.

The results for the UA ordered on 12/19/24, revealed there was escherichia coli and the final report was completed on 12/24/24. The laboratory form was signed by the physician on 12/31/24. It was noted by RN 1

on 12/27/24.

A nursing progress note dated 12/27/24 at 3:12 PM, revealed that laboratory provided results and the NP ordered to start on Bactrim twice daily for 7 days.

On 2/5/25 at 9:46 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated if a resident complained of signs and symptoms of a UTI, she contacted the physician. RN 1 stated laboratory results were documented in the Medication Administration Record (MAR). RN 1 stated if the nurse prior to her obtained labs for a resident, then she would watch for the results from the laboratory. RN 1 stated UA results were sent to the facility quickly and the culture took about 3 days. RN 1 stated the results were faxed to the facility. RN 1 stated sometimes nurses needed to call the lab, and have the results faxed. RN 1 stated she did not know what happened with resident 6's UA results.

On 2/5/25 at 9:53 AM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident had signs and symptoms of a UTI, the physician was contacted for orders. The DON stated if the physician ordered a UA then an order was placed in the medical record and the nurse obtained a sample.

The DON stated the lab then picked up the sample. The DON stated usually results were faxed to the facility.

The DON stated he was able to log into the laboratory portal for the results. The DON stated labs were also available to nurses through the residents medical record.

3. Resident 25 was admitted to the facility on [DATE REDACTED] with diagnoses which included dementia, cervicalgia, need for assistance with personal cares, and anxiety.

On 1/27/25 at 11:05 AM, an observation was made of resident 25 at the nurses station. Resident 25's room was observed to have a strong urine odor. Resident 25 was observed to wheel himself to his room in his wheelchair. Resident 25 was asking staff to open the door to his room.

On 1/30/25 at 1:28 PM, an observation was made of resident 25's room. The room had a strong urine odor. Resident 25 was not in his room.

On 2/3/25 at 1:10 PM, an observation was made of resident 25. Resident 25 was in the hallway asking staff to go into his room. Resident 25 was not taken to the restroom. Resident 25 was observed to ask visitors to open the door to his room. Resident 25 was observed to have a strong urine odor.

On 2/5/25 at 10:42 AM, an observation was made of resident 25. Resident 25 was observed at the nurses station with a urine odor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0690 Resident 25's medical record was reviewed on 1/27/25 through 2/6/25.

Level of Harm - Actual harm A nursing bowel and bladder screener dated 5/29/24, revealed resident 25 was a candidate for scheduled toileting (timed voiding) and was not currently on a toileting program. There was no additional information. Residents Affected - Few

A care plan dated 5/23/24, revealed [Resident 25] has had occasional bladder incontinence r/t [related to] decreased mobility. The goal was resident 25 would not have increased incontinence through the next review. The interventions included to assist with toileting as the resident requested and as needed, monitor for increased incontinence and use pull-ups.

On 1/28/25 at 3:34 PM, an interview was conducted with CNA 1. CNA 1 stated she was not aware of a bowel and bladder retraining program for residents. CNA 1 stated if there was a retraining program there would be

a paper behind the residents door with times on it. CNA 1 stated resident 31 was on a retraining program. CNA 1 stated that meant staff took resident 31 to the bathroom at 2:00 PM, between 4:00 and 5:00 PM, after dinner, and then before bed which was 4 times during the evening shift. CNA 1 stated she was not sure if resident 25 was on the same program. CNA 1 stated resident 25 was continent and let staff know when he needed to use the restroom.

48709

4. Resident 31 was admitted to the facility on [DATE REDACTED] with diagnoses which included malignant neoplasm of cerebellum, unspecified mood [affective] disorder, disorders of bladder, major depressive disorder, anxiety disorder, neuralgia and neuritis, systemic lupus erythematosus and hypertension.

On 1/27/25 at 9:34 AM, an interview was conducted with resident 31's family member. Resident 31's family member stated the facility, threw [resident 31] in a brief. The family member stated that resident 31 had to rely on staff to take her to the bathroom and sometimes staff did not answer her call light and she would have to call the family member and then the family member would have to call the nurse's station or go to the facility themselves to help the resident to the bathroom. The family member stated they felt like staff used the brief because they were short-staffed.

On 1/30/25 at 10:28 AM, an interview was conducted with resident 31. Resident 31 stated staff would put a brief on her all the time without asking her if that was what she wanted and that she had to start wearing them all of the time during the Covid outbreak. Resident 31 stated she got used to wearing a brief. Resident 31's family member stated she took resident 31 to see a urologist because she was having frequent urination and she did not always have to wear a brief. Resident 31 stated if she could get up on her own, she would not have to wear a brief because I could get to the bathroom and that was why they started working on walking with a walker.

Resident 31's medical record was reviewed 1/27/25 through 2/6/25.

A Quarterly Minimum Data Set (MDS) dated [DATE REDACTED] indicated a Brief Interview for Mental Status (BIMS) score of 14. A BIMS score of 13 to 15 indicated cognition was intact.

The following NSG-Bowel and Bladder Screener indicated:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0690 a. An admitted d 5/20/24 Always voided appropriately without incontinence with assistance of 1 person. Confused, needed prompting and was usually aware of the need to toilet. No current toileting program was Level of Harm - Actual harm currently being used. Candidate for Schedule toileting (timed voiding).

Residents Affected - Few b. An other dated 8/18/24 Not always, but at least daily voided appropriately without incontinence with assistance of 1 person. Confused, needed prompting and was usually aware of the need to toilet. No current toileting program was currently being used. Candidate for Schedule toileting (timed voiding).

c. An other dated 11/18/24 Not always, but at least daily voided appropriately without incontinence with assistance of 1 person. Forgetful but followed commands and was usually aware of the need to toilet. No current toileting program was currently being used. Candidate for Schedule toileting (timed voiding).

A physician's order indicated Tamsulosin HCL Oral Capsule 0.4 MG was started on 10/2/24 at bedtime for urine retention.

An Ultrasound Imaging Appointment in [Hospital name redacted] Radiology report, dated 11/15/24 indicated, FINDINGS: Kidneys: Renal echogenicity is normal. There is no hydronephrosis. Bladder: Views of the bladder are unremarkable.

The care plan dated 5/17/24 revealed, [Resident 31] has weakness. She has impaired vision on her left side.

She has an ADL [activities of daily living] self-care performance deficit. The goal was [Resident 31] will maintain her current functional ability through next review. An intervention dated 5/17/24 was Toilet use: The resident requires partial/moderate assist for toilet use; [Resident 31] has had occasional urinary incontinence; [Resident 31] will have no increased in episodes of urinary incontinence through next review; Assist with toileting at resident request; Monitor for increased incontinence; and Pull-ups.

The facility policy, Quality of Care Incontinence Urinary Incontinence, dated 5/4/23, indicated, The facility will consider various modifiable factors when determining ways to assist the resident to acheive his/her highest practicable level of functioning related to bladder incontinence.

On 2/4/25 at 1:12 PM, an interview was conducted with the Lead Certified Nurse Assistant (CNA). The Lead CNA stated that the facility had a toileting program in the past, but that they did not have one now. The Lead CNA stated that when a resident was on a toileting program they would have to take them to the restroom every 2 hours. The Lead CNA stated resident 31 needed assistance to get to the bathroom with her walker or wheelchair and that she was aware when she had to void and was assisted to the bathroom upon request.

The Lead CNA stated resident 31 wore a pull-up during the day and at night she would be put in a tabbed brief.

On 2/4/25 at 3:14 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated he was assigned to the 300 hallway and that he was not aware of any resident that was on a toileting program. LPN 1 stated he did not receive any education on a toileting program.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0690 On 2/4/25 at 3:21 PM, an interview was conducted with RN 4. RN 4 stated the facility did not currently have a toileting program. RN 4 stated a toileting program would benefit a resident who was aware of the need to Level of Harm - Actual harm void or someone who needed assistance to get to the restroom. RN 4 stated any nurse can fill out the bowel and bladder evaluation and if a resident was a candidate the nurse should talk to the unit manager. Residents Affected - Few

On 2/4/25 at 3:26 PM, an interview was conducted with the UM. The UM stated there were no residents currently on the toileting program. The UM stated the resident did not need to agree to a toileting program and the residents with dementia were the target. The UM stated that if a resident was on the toileting program, staff would take them to the bathroom every 2 to 3 hours. The UM stated the purpose of a toileting program was to help those who may have lost independence of going to the bathroom on their own, to encourage continence, and be able to go home. The UM stated she had never had a resident ask to be put

on the toileting program. The UM stated the toileting program would help benefit resident 31 and that she would be a good candidate for the program to help her not decline and improve. The UM stated that if the bowel and bladder evaluation indicated she was a candidate for the program then it should be on the care plan and CNA's would be aware and be documenting that.

On 2/5/25 at 9:17 AM, an interview was conducted with RNC 1. RNC 1 stated if a resident was incontinent and if the resident expressed a want to toilet themselves it would be in their care plan.

On 2/5/25 at 9:23 AM, an interview was conducted with the DON. The DON stated a bladder and bowel assessment was completed upon admission and nursing would review it. The DON stated if a resident was

on a toileting program, it would be on the care plan and Kardex which would allow staff to know they needed assistance with toileting. The DON stated a resident that they were trying to help restore continence would be put on a schedule. The DON stated resident 31 was aware when she needed to use the restroom and would be assisted to the restroom when she called for assistance. The DON stated she wore a brief for accidents.

On 2/5/25 at 12:27 PM, an interview was conducted with RNC 2. RNC 2 stated research showed bowel and bladder retraining programs did not work, so facilities did not do them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30563 potential for actual harm Based on interview, and record review, it was determined, for 1 of 33 sampled residents, that the facility Residents Affected - Few failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a peripherally inserted central catheter (PICC) line had no physician orders for care for 10 days after the line was placed. Resident identifier: 3.

Findings include:

Resident 3 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses which included infection and inflammatory reaction due to other cardiac and vascular devices, methicillin-resistant Staphylococcus aureus (MRSA), end stage renal disease and dialysis.

Resident 3's medical record was reviewed 1/27/25 through 2/6/25.

A nursing progress note dated 12/28/24 at 5:00 PM revealed, [PICC/Midline placement company] came out to the building an [sic] placed a midline. Resident tolerated procedure with minimal pain. First dose of IV [intravenous] ABX [antibiotic] Vancomycin started.

A physician's order dated 1/7/25 at 6:00 PM revealed, PICC/Midline: Flush IV line before and after medication administration every shift.

A physician's order dated 1/7/25 at 6:00 PM revealed, PICC/Midline: If no meds/fluids, flush with 5-10ml NS [normal saline] q [every] 12 hours every shift.

A Physician's order dated 1/7/25 at 6:00 PM revealed, PICC/Midline: Site observation (redness, warmth, swelling, pain, itching) every shift.

A physician's order dated 1/8/25 at 6:00 AM revealed, Central Line/PICC/Midline: Dressing and cap change Weekly & PRN [as needed] every day shift every Wed [Wednesday].

A physician's order dated 1/8/25 at 6:00 AM revealed, PICC/Midline: Change tubing Q day every day shift.

A nursing progress note dated 1/20/25 at 10:51 PM, PICC/Midline Site with mild swelling, large amount of dried blood at insertion site and under dressing, insertion site appears red and inflamed

Dressing changed performed with sterile technique Concerned midline is infected and/or no longer patent Provider, don, um made will be aware in morning feedback.

On 1/29/25 at 9:25 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated she did not know what was going on with resident 3's PICC/Midline flushes, dressing changes and cap changes. RN 2 stated there were no orders for the PICC line for a while after it was placed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0694 On 1/30/25 at 1:00 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated a resident with a PICC/Midline needed a physician's orders to be flushed before and after medication was Level of Harm - Minimal harm or administration. LPN 2 stated the PICC/Midline usually had a physician's order to have the dressing changed potential for actual harm every 5 to 7 days. LPN 2 stated if a resident was not administered a medication through the PICC/Midline, then the PICC/Midline needed to be flushed every shift. LPN 2 stated there needed to be physician's order to Residents Affected - Few flush the PICC/Midline line. LPN 2 stated as long as the line was there, there needed to be physician's orders to flush and change the dressing.

On 1/30/25 at 1:30 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated there was an outside source who placed PICC lines after the physician ordered it. RN 1 stated a PICC line needed to be flushed to make sure it was flowing with no blockage. RN 1 stated the nurse needed to assess the PICC site and look for redness or itching. RN 1 stated vital signs should be done every shift which included looking for signs or symptoms of infection. RN 1 stated the dressing to the PICC line needed to be changed weekly or as needed if it was peeling. RN 1 stated she performed a sterile process to change the dressing weekly. RN 1 stated if there was not a physician's order, then the nurse needed to contact the physician. RN 1 stated

she would know from nurse to nurse report at the start of her shift if someone had a PICC line and then she would look for physician's orders.

On 2/3/25 at 1:31 PM, an interview was conducted with the Director of Nursing (DON) and Regional Nurses Consultant (RNC) 1. The DON stated a PICC/Midline should be flushed before and after medication administered. The DON stated the PICC/Midline needed to be flushed daily if no medication was administered.

On 2/4/25 at 9:16 AM, a follow up interview was conducted with RNC 1. RNC 1 stated there were no order to do PICC cares in resident 3's medical record until 1/7/25 and the PICC was placed on 12/28/24. RNC 1 stated PICC cares needed to be done when medication was administered and once per shift. RNC 1 stated

the shifts were 12 hours. RNC 1 stated the PICC needed to be flushed with 5-10 milliliters of NS every shift. RNC 1 stated there were no physician's orders on how often, what to do or how to care for the PICC prior to 1/7/25.

The facility provided a policy and procedure titled Clinical Services Policy and Guidelines for Implementation which revealed the following:

PURPOSE: To assure that residents receive care and services for the provision of parenteral

fluids consistent with professional standards of practice, including competent staff, in

consideration of the resident's plan of care, accepted infection control practices and monitoring

for complications.

POLICY: The facility will provide parenteral fluids consistent with professional standards of

practice and in accordance with physician orders, the comprehensive person-centered care

plan and the resident's goals and preferences. Accepted infection control practices will be used

and the resident will be monitored for complications.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0694 GUIDELINES:

Level of Harm - Minimal harm or 1. Facility staff will use appropriate hand hygiene while administering and caring potential for actual harm for parenteral devices and providing IV services. Residents Affected - Few 2. When placing a venous access device aseptic technique will be used.

3. Appropriate personal protective equipment will be used while inserting, removing

or otherwise manipulating venous access devices.

4. Parenteral fluids will be administered according to physician orders.

5. Parenteral therapy will be administered according to the resident-centered care plan, in

accordance with the resident's goals, preferences and advance directives, as

appropriate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30563 potential for actual harm Based on observation, interview, and record review it was determined for, 5 of 33 sampled residents, that the Residents Affected - Some facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, the facility did not have oxygen orders for residents. In addition the facility did not follow their processes with labeling and dating the oxygen tubing and the humidifier water. Resident identifiers: 11, 14, 29, 32 and 34.

Findings Included:

1. Resident 29 was admitted to the facility on [DATE REDACTED] which included chronic respiratory failure with hypoxia, congestive heart failure and muscle weakness.

On 1/27/25 at 9:45 AM, an interview was conducted with resident 29. Resident 29 stated her oxygen tubing was changed when she asked staff to change it. Resident 29 stated if the nasal cannula fell on the floor they provided her new oxygen tubing and nasal cannula. Resident 29 stated the water and the tubing were not changed regularly. Resident 29's oxygen was observed. There were no dates on the oxygen tubing. There was a bag on the concentrator with no date. The water on the concentrator was not dated. The water was almost empty.

Resident 29's medical record was reviewed 1/27/25 through 2/6/25.

A care plan dated 3/28/23 revealed [Resident 29] has potential for altered respiratory status r/t [related to] hypoxic respiratory failure, sleep apnea. The goal was [Resident 29] will have no unreported s/s [signs and symptoms] respiratory distress through next review. One of the interventions was O2 [oxygen] as ordered; monitor O2 sats as ordered.

Resident 29's physician's orders revealed the following:

a. On 6/24/24, Oxygen 0-5 liters per nasal cannula or mask to keep sats > [greater than] 90%. Document O2 sats and liters per minute every shift.

b. On 6/24/24, Change oxygen tubing, concentrator bottle (if needed) and clean filter every week every day shift every Fri [Friday].

According to the Treatment Administration Record for January 2025 revealed oxygen was changed 1/3/25, 1/10/25, 1/17/25, 1/24/25 and 1/31/25. There was no documentation that the tubing was changed on 1/27/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0695 On 1/28/25 at 3:56 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated there were concentrators in each resident room for residents who needed oxygen. CNA 2 stated there were Level of Harm - Minimal harm or portable oxygen tanks for when residents who left their rooms. CNA 2 stated there was tubing and water for potential for actual harm the concentrators. CNA 2 stated the oxygen tubing and water were checked daily. CNA 2 stated the tubing and water were changed weekly. CNA 2 stated when water was empty then staff changed the water Residents Affected - Some container and tubing. CNA 2 stated the tubing was dated on tape and the water container was dated with a black marker. CNA 2 observed resident 29's oxygen was changed on 1/27/25. An observation was made of resident 29's oxygen and there was a piece of tape with the date of 1/27/25, the water container was full with

a date of 1/27/25 and a plastic bag was on the oxygen concentrator dated 1/27/25.

On 1/28/25 at 3:32 PM, an interview was conducted with CNA 1. CNA 1 stated staff change out the oxygen tubing, nasal cannula and the water containers every Friday. CNA 1 stated the items were dated with tape around the tubing and black marker on the water. CNA 1 stated oxygen supplies were changed weekly to keep them clean from parasites for the resident to be able to breath correctly. CNA 1 stated the respiratory system was very important for elderly who needed oxygen. CNA 1 stated the previous Friday she did not work.

On 2/5/25 at 2:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated oxygen tubing and water container were changed weekly. The DON stated there was a physician's order in each resident's medical record for nurses to sign off after it had been changed. The DON stated each resident with oxygen should have a plastic bag on the concentrator that was dated. The DON stated the tubing and water container needed to have a date written on them. The DON stated he did not know why there was no date on resident 29's oxygen when the order was to be changed every Friday. The DON stated

he did not know why the nurse signed off that the oxygen supplies were changed 1/24/25. The DON did not provide additional information why the tubing, bag and water container were not dated.

43212

2. Resident 32 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED] with diagnoses that included sleep related hypoventilation, and congestive heart failure.

On 1/27/25 at 1:43 PM, an interview was conducted with resident 32 who stated he used oxygen only at night. Resident 32 was observed to have an oxygen concentrator with no labeling on the oxygen tubing.

Resident 32's medical record was reviewed 1/27/25 through 2/6/25.

A quarterly Minimum Data Set (MDS) dated [DATE REDACTED] revealed, oxygen therapy, response No.

Resident 32's physician orders were reviewed. No oxygen orders could be found in resident 32's physician orders.

Resident 32's care plan was reviewed. No care area for the use of oxygen could be found in resident 32's care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0695 Resident 32's MAR (Medication Administration Record) and TAR (Treatment Administration Record) for January 2025 was reviewed. No orders were found for use of oxygen. Level of Harm - Minimal harm or potential for actual harm Resident 32's progress notes revealed:

Residents Affected - Some On 9/24/24 at 1:33 PM, a LTC [long term care] charting note revealed, .Vitals: Most recent O2 [oxygen] sats- [saturations] O2 90%-9/24/24 3:21 PM Method: Room Air .Respiratory .Does resident use supplemental oxygen: Yes; Route: Nasal Cannula .

On 1/7/25 at 11:31 AM, a LTC charting note revealed, Vitals: .Most recent O2 sats-O2 94%-12/16/24 8:57 AM Method: Room Air .Respiratory .Does resident use supplemental oxygen: No .

On 1/8/25 at 1:37 AM, an Orders-Administration note revealed, Room Air Trial; Nurse to collect 4 readings 5 min [minutes] apart if patient SPO2 [oxygen saturation of pulse] and document in nursing note every shift for 7 day(s) for 2 Days: 5 min [minutes]: 94%; 10 min: 90%; 15 min: 93%; 20 min: 90%.

On 1/9/25 at 10:42 PM, a nursing progress note revealed, Patient O2 sats on room air trial: 96%, 93%, 92%, and 92%.

On 1/11/25 at 6:28 PM, a nursing progress note revealed, SPO2 obtained today; 3:07 PM-92; 3:12 PM-90; 3:17 PM-93, 3:22 PM-93.

On 1/29/25 at 3:03 AM, a nursing progress note revealed, 2110 [9:10 PM] Pt [patient] reported chills and not feeling right .O2 [oxygen] 94 3 L [liters] NC [nasal cannula] .

A provider progress note dated 9/16/24 revealed, .On recent nights, he has had higher oxygen needs, as much as 5 L by NC or mask, otherwise asymptomatic. He states that he had a Dx [diagnosis] of OSA [Obstructive Sleep Apnea] years ago, had not really had any follow-up since then and felt he did not need it, but now he feels that it may be time .Dyspnea, unspecified; oxygen 2L NC PRN [as needed], clear lungs . Having nocturnal hypoxemia with significant desats, stable overall and sleeping well, per report he has had a history of OSA in the past; continue nighttime oxygen and monitor; refer to sleep clinic for evaluation.

A provider progress note dated 11/18/24 revealed, .Problem list .Dyspnea; sleep related hypoventilation in conditions classified elsewhere .Assessment/Plan .Having nocturnal hypoxemia with significant desats, stable overall and sleeping well, per report he has had a history of OSA in the past; continue nighttime oxygen and monitor; refer to sleep clinic for evaluation.

A provider progress note dated 12/19/24 revealed, .Problem list .Dyspnea; sleep related hypoventilation in conditions classified elsewhere .Assessment/Plan .Having nocturnal hypoxemia with significant desats, stable overall and sleeping well, per report he has had a history of OSA in the past; continue nighttime oxygen and monitor, refer to sleep clinic for evaluation.

On 2/4/25 at 8:32 AM, an interview was conducted with CNA 4 who stated resident 32 used oxygen most of

the time. CNA 4 stated resident 32 used oxygen when receiving dialysis and throughout the night but did not use it when he was in his wheelchair.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0695 On 2/4/25 at 10:33 AM, an interview was conducted with the Lead CNA who stated resident 32 used 2 liters of oxygen. The Lead CNA stated resident 32 did not use oxygen when in his wheelchair, but did use it while Level of Harm - Minimal harm or at dialysis and while in bed. potential for actual harm

On 2/5/25 at 3:29 PM, an interview was conducted with the Regional Nurse Consultant (RNC) 2 who stated a Residents Affected - Some provider note on 9/16/24 documented resident 32 was feeling short of breath. RNC 2 also stated that on 9/16/24 resident 32 had an order for vital signs every 4 hours. RNC 2 stated a physician referral was placed

on 9/16/24 for an in lab sleep study test DX [diagnosis]; insomnia, daytime sleepiness, fatigue, hypoxia. RNC 2 stated referrals were placed at 10 different facilities by the transportation manager and none of the facilities would accept the referral. RNC 2 stated a second referral for in home sleep study test DX: Insomnia, daytime sleepiness, fatigue, hypoxia was placed on 11/25/24. RNC 3 stated the test was completed on 1/21/25. The RNC stated the transportation manager did not keep a record of who she contacted for the original sleep study and on what dates. RNC 2 stated resident 32 did not have an oxygen order when he was readmitted

on [DATE REDACTED]. RNC 2 stated resident 32 did not have an oxygen order on his initial admission. The RNC stated that when an order was given for oxygen, the nurse or the nurse manager were responsible to put the order into the resident's medical record. RNC 2 stated the order should include keeping the resident's oxygen saturation above 90%, and can be addended to be more specific. RNC 2 stated oxygen orders should be part of the resident's regular care plan under oxygen or respiratory care. RNC 2 stated the nurse was responsible to verify that the resident received the ordered oxygen and could delegate to the CNA to make sure the oxygen was on the resident if they needed it. RNC 2 stated if a resident refused, the CNA would notify the nurse and the nurse would document the refusal.

3. Resident 34 was admitted to the facility on [DATE REDACTED] with diagnoses that included obstructive sleep apnea.

On 1/27/25 at 11:17 AM, an interview was conducted with resident 34 who stated he used oxygen all the time. An observation was made of the oxygen concentrator. The oxygen tubing was not labeled or dated. Resident 34 was observed not to be wearing his oxygen during the interview. Resident 34 stated he was not wearing it because he could not find it and had not called staff to help him find it. Resident 34 was observed to be laying on top of his oxygen tubing.

Resident 34's medical record was reviewed between 1/27/25 and 2/6/25.

On 7/31/24, an IP [inpatient] transfer report from the hospital revealed, .Plan .Pulm [pulmonary]: Nocturnal hypoxia; Has required 1-2 L overnight both here and at [hospital] before admission, continue CPAP [Continuous Positive Airway Pressure], inpatient sleep study done, f/u results; Will discuss mask options with RT [respiratory therapist], Long-term Comprehensive Rehabilitation Issues(taken from H & P [history and physical] 7/9/24): Pulmonary: Nocturnal hypoxia, suspected OSA; Patient with several witnessed apneic events at home prior to stroke, intermittently using his father's nocturnal O2. Required noctural O2 while on rehab, improved with CPAP. Additionally, muscle/tissue flaccidity d/t [due to] stroke further predispose to OSA. Supplemental O2 if needed to keep sats >90%, ISS [injury severity score], Appreciate SLP [speech language pathologist] evaluation and recs [recommendations], CPAP at night, Working on sleep study while inpatient .Discharge planning: .Dad reports that pt often suffers from SOB [shortness of breath] prior to admit and uses his dads O2 at home at times .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0695 Resident 34's physician orders were reviewed. No oxygen orders could be found in resident 34's physician orders. Level of Harm - Minimal harm or potential for actual harm Resident 34's care plan was reviewed. No care area for the use of oxygen could be found in resident 34's care plan. Residents Affected - Some Resident 34's MAR (Medication Administration Record) and TAR (Treatment Administration Record) for January 2025 was reviewed. No orders were found for use of oxygen.

Resident 34's progress notes revealed:

a. On 7/31/24 at 2:35 PM, a clinical admission note revealed, .O2 92% Method: Room air .Respiratory: Lungs clear throughout bilaterally. No difficulty breathing. No cough noted. No shortness of breath noted .

b. On 7/31/24 at 10:20 PM, a Daily Skilled Charting note revealed, O2 sats O2 92% Method: Room Air . Respiratory: Does the resident use supplemental oxygen-Yes .Route: Nasal Cannula; Liter Per Minute (LPM) no response, Frequency: Continuous

c. On 1/9/25 at 10:44 PM, a nursing note revealed, Note text: O2 sats on room air trial: 91%, 91%, 89%, and 90%.

d. On 1/11/25 at 6:33 PM, a nursing note revealed, Note text: SPO2 obtained: 3:05 pm-93, 3:10 pm-95, 3:15 pm-93, 3:20 pm-95.

e. On 1/13/25 at 8:00 AM, a Psych follow-up note revealed, .He is suppose [sic] to be on bipap [bilevel positive airway pressure] per his report. He had a sleep study at the [hospital] while hospitalized , was having some problems prior to stroke. He used pap machine while at [hospital]. He was told they would have a machine here at the facility. He did okay with bipap, had a dry mouth, he thinks that his oxygen machine does not have a strong enough flow, He would like it checked. 12-16-24 reminder to locate sleep study so he can obtain bipap for sleep .He does not have a cpap machine yet .He would like to know if his sleep study from the [hospital] was found and if medical is working toward bipap machine or if this is waiting for insurance to be straightened out. He reports he was treated with bipap at the [hospital] and was told they would have a machine here for him. He thinks he has trouble breathing out and by using oxygen in the day

he thinks it helps him feel like he can breath out better .need BIPAP machine and location of sleep study from [hospital] .Obstructive sleep apnea, bipap; Obstructive sleep apnea (adult) (Pediatric).

On 8/2/24 a Provider admission note revealed, .He did not wear oxygen prior to hospitalization . Family report he was diagnosed with OSA in the hospital and did wear a cpap in hospital. Continue oxygen especially at night .Obstructive sleep apnea (adult) (pediatric) .Respiratory: Lungs CT, OTHER: 2L via NC . Obstructive sleep apnea (adult) (pediatric); CPAP in hospital; use oxygen 2L via NC keep O2 sats above 92%.

On 1/20/25 a provider progress note revealed, .Obstructive sleep apnea (adult) (pediatric); cpap in hospital, use oxygen 2L via NC keep O2 sats above 92%.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0695 On 2/4/25 at 8:32 AM, an interview was conducted with CNA 4 who stated resident 34 used oxygen all the time. CNA 4 stated resident 34 frequently took his oxygen tubing off and staff had to go in and encourage Level of Harm - Minimal harm or him to put it back on. CNA 4 stated the Lead CNA was responsible for changing the oxygen tubing on the potential for actual harm oxygen concentrators. CNA 4 stated the task was performed yesterday.

Residents Affected - Some On 2/5/25 at 2:54 PM, an interview was conducted with the DON [Director of Nursing] who stated he did not see any discharge orders from the hospital for resident 34 to have oxygen. The DON reviewed resident 34's medical record and confirmed he did not have orders for oxygen. The DON stated resident 34 did not have orders for oxygen use even though he was getting it sometimes.

4. Resident 11 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses that included coronary artery disease, congestive heart failure, and respiratory failure.

On 1/27/25 at 1:36 PM, resident 11 was observed to be wearing oxygen while laying in bed. The surveyor observed that there was no labeling on the oxygen tubing.

Resident 11's medical records were reviewed between 1/27/25 and 2/6/25.

A review of resident 11's physician orders revealed:

a. On 2/2/25, Obtain O2 sats on room air. Apply O2 to keep sats >90% every shift.

b. On 2/25/25, Oxygen: O2 @ 0-5 liters per minute via nasal cannula to keep SPO >90% as needed for O2 stats [sic] ,90%.

c. On 2/2/25, Oxygen: weekly change out & cleaning equipment change O2 tubing, bubbler, filter (if soiled), and wipe down concentrator, every day shift every Friday related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA.

A review of resident 11's January MAR/TAR revealed on 6/28/24 and discontinued on 2/2/25, Change oxygen tubing, concentrator bottle (if needed) and clean filter every week every day shift every Fri. The TAR revealed oxygen tubing changes and filter changes were not completed on 1/24/25 and 1/31/25.

5. Resident 14 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED] with diagnoses that included heart failure, chronic obstructive coronary disease, and respiratory failure.

On 1/27/25 at 9:56 AM, an interview was conducted with resident 14 who stated she wore oxygen all the time. Resident 14 stated she was not wearing her oxygen at the time because she had just gotten out of the shower. Resident 14 stated she believed the staff changed her oxygen tubing every 3 months.

Resident 14's medical records were reviewed between 1/27/25 and 2/6/25.

A review of resident 14's physician orders revealed:

a. On 2/2/25, Oxygen: weekly change out & cleaning equipment change O2 tubing bubbler, filter (if soiled), and wipe down concentrator, every day shift every Fri related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0695 b. On 2/2/25, Oxygen: O2 @ 0-5 liters per minute via nasal cannula to keep SPO >90% every shift.

Level of Harm - Minimal harm or c. On 2/2/25, Obtain O2 sats on room air. Apply O2 to keep sats >90% every shift. potential for actual harm

A review of resident 14's January MAR/TAR revealed on 6/24/24 May apply oxygen per nasal cannula or Residents Affected - Some mask titrate to keep sats >90%. Document O2 sats and liters per minute. Notify MD for initiation of use, as needed for O2 sats ,90%. The TAR revealed oxygen was applied on 1/5/25.

On 2/4/25 at 10:33 AM, an interview was conducted with the Lead CNA who stated she was the staff member who changed the oxygen tubing and it was changed every Friday. The Lead CNA stated when changing oxygen tubing, she placed tape on the tubing and put the date the tubing was changed. The Lead CNA stated the nurse documented when the oxygen tubing was changed in the computer.

On 2/4/25 at 11:04 am, an interview was conducted with RN 4 who stated a physician order was necessary for residents who used oxygen. RN 4 stated the order should include if a nasal cannula or mask should be used and how many liters of oxygen the resident should be using. RN 4 stated sometimes the order stated PRN or continuous to keep saturations above 90%.

On 2/5/25 at 2:54 PM, an interview was conducted with the DON who stated the cannulas for each resident were changed weekly. The DON stated there was an order for that and the nurse would document when it was completed. The DON stated the nurse or the nurse manager were responsible for putting oxygen orders

in the resident's medical chart.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30563 potential for actual harm Based on interview and record review it was determined, for 2 of 33 sampled residents, that the facility did Residents Affected - Few not ensure that residents who required dialysis received such services, consistent with professional standards of practice. Specifically, resident's receiving dialysis were not provided a fluid restriction as ordered from dialysis. Resident identifier 3 and 32.

Findings include:

1. Resident 3 was admitted to the facility on [DATE REDACTED] with diagnoses which included infection and inflammatory reaction due to other cardiac and vascular devices, end stage renal disease with dialysis, Methicillin-resistant Staphylococcus aureus, surgical after care following surgery on the circulatory system, anemia, diabetes mellitus and Alzheimer's disease.

Resident 3's medical record was reviewed 1/27/25 through 2/6/25.

The current diet order dated 1/10/25 CCD (carbohydrate controlled), renal diet, Regular RG7 (regular) texture, thin consistency, 1 gram sodium.

There was no physician's order for a fluid restriction.

A care plan dated 7/7/23 and revised on 1/19/24 revealed resident 3 had fluid retention after dialysis and was encouraged to follow her 1 liter fluid restriction. One of the interventions was to remind resident 3 about her fluid restriction as needed. Another care plan dated 7/3/23 and revised on 12/6/23 revealed resident 3 was non compliant with her fluid restriction. There were no interventions on what to do when resident 3 was non-compliant.

A Nutritional Evaluation dated 12/16/24 revealed in the assessment section, .Has 1.5 liter/day fluid restriction that she is often non-compliant with. No recommended changes at this time. Will continue to monitor and assist prn [as needed].

A form titled Communication Report from resident 3's dialysis dated 1/17/25 revealed Reinforced low sodium diet & fluid restriction, Pt [patient] acknowledge understanding.

A form titled Communication Report from resident 3's dialysis dated 1/22/25 revealed Reinforced diet & Fluid restriction. Pt acknowledged understanding.

A form titled Communication Report from resident's dialysis dated 1/24/25 revealed .reinforced diet & fluid restrictions. Pt acknowledged understanding.

On 1/29/25 at 9:25 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated residents who needed to be on fluid restrictions were not on fluid restrictions. RN 2 stated nurses did not know how much fluid residents were provided because there was no tracking system.

43212

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0698 2. Resident 32 was admitted to the facility on [DATE REDACTED], and readmitted on [DATE REDACTED] with diagnoses that included end stage renal disease, dysphagia, protein calorie malnutrition, type 2 diabetes and cirrhosis of the Level of Harm - Minimal harm or liver. potential for actual harm Resident 32's medical record was reviewed between 1/27/25 and 2/6/25. Residents Affected - Few Physician orders were reviewed. Resident 32's diet order revealed:

a. On 8/5/24, Renal diet, Regular RG7 texture, thin consistency; Liberal Renal CCD [controlled carbohydrate]. It should be noted that resident 32 did not have an order for a fluid restriction.

b. [Provider] Dialysis to provide in-house dialysis treatment up to 3x a week.

Resident 32's care plan dated 7/20/23 revealed, [Resident 32] is receiving dialysis r/t [related to] ESRD [End stage renal disease]. The goal was, [Resident 32] will have not s/s [signs and symptoms] of complications from dialysis through the review date. Interventions included, Monitor/document/report PRN [as needed] new/worsening peripheral edema.

Resident 32's progress notes included:

a. On 1/15/25 at 1:00 PM, a nursing progress note revealed, resident to dialysis et [sic] back again with suggestion to encourage him to follow fluid restriction.

b. On 1/31/25 at 3:40 PM a nursing progress note revealed, .Acknowledges understanding the importance of achieving optimal results by completing treatment and adhering to fluid restriction.

Resident 32's dialysis communication notes were reviewed and revealed:

a. On 11/25/24, a dialysis communication report revealed, . Reinforced diet & fluid restriction, pt acknowledged understanding.

b. On 12/13/24, a dialysis communication report revealed, .Enforced diet and fluid restriction. Pt acknowledged understanding.

c. On 12/24/24, a dialysis communication report revealed, . Reinforces diet and fluid restriction. Pt acknowledged understanding.

d. On 1/24/25, a dialysis communication report revealed, .Please have him follow fluid restrictions & diet.

e. On 1/31/25, a dialysis communication report revealed, .Reinforced diet and fluid restriction. Pt acknowledged understanding.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0698 On 2/3/25 at 12:23 PM, an interview was conducted with the Registered Dietitian (RD) who stated resident 32 sometimes switched back and forth with watching his fluid intake. The RD stated she did not believe Level of Harm - Minimal harm or resident 32 was on a fluid restriction. The RD stated resident 32 would need a physician order to be on a potential for actual harm fluid restriction. The RD stated she communicated with the dialysis RD through email and received a report card on each resident receiving dialysis. The RD stated she had access to all the notes of the dialysis RD, Residents Affected - Few including lab reports and dry weights and did not recall a mention of a fluid restriction. The RD stated resident 32 had discussed his fluid gains with her and she had given him simple tips on how to reduce his fluid intake. The RD stated she had not given resident 32 specific restrictions or anything set in stone. The RD stated resident 32 was monitoring himself as he needed to, and they were not going to tell him he can't drink. The RD stated resident 32's fluid intake was documented in the CNA's Point of Care (POC) tasks. The RD stated, Maybe since there is not an order for it, it is not being implemented.

On 2/6/25 at 12:39 PM, an interview was conducted with the Director of Nursing (DON) who stated the dialysis RD would send an email to the DON, the Unit Manager, and the RD to let them know what she wanted regarding a fluid restriction. The DON stated resident 32 had signed a risk/benefit form indicated that

he chose not to follow his dietary recommendations and that it should be in his medical record.

On 2/6/25 at 3:00 PM, an interview was conducted with the Unit Manager ( UM) who stated there were a few residents who were on fluid restrictions, and if resident 32 were on a fluid restriction it would be in the MAR (Medication Administration Record). The UM stated the order would include how much of a fluid restriction for dietary and for nursing for a 24 hour period. The UM stated there should be a box to type in the amount in ml's [milliliters] on the resident's dietary profiles. When asked if resident 3 was on a fluid restriction, the UM stated she thought all the dialysis patients are on fluid restrictions. The UM stated if there was a new order from the dialysis RD, she would get an email or a fax with the new order. The UM stated she had not reviewed every dialysis sheet that came with residents after dialysis. The UM stated she did not think that resident 32 was on a fluid restriction. The UM stated if it was not on the diet order, the nurses would not know about it.

The facility dialysis Policy and Guidelines revised on 5/2019 revealed the following:

Purpose: To provide residents with hemodialysis or peritoneal dialysis that is consistent with professional standards of practice and consistent with the individuals assessment and goals.

Policy: The facility will provide residents, who require dialysis, care and service consistent with professional standards of practice, a comprehensive person-centered care plan and inclusive of the residents' goals and preferences.

Guidelines: .

4. The facility and the dialysis center will collaborate to assure that the resident's needs related to dialysis treatments are being met.

9. There will be ongoing communication between the facility and the dialysis center reflected in the medical record. This communication may include but not limited to: .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0698 d. Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output Level of Harm - Minimal harm or measurements as ordered. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0742 Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress Level of Harm - Actual harm disorder.

Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48709

Based on observation, interview, and record review, for 1 of 33 sampled residents, it was determined that the facility failed to ensure that a resident who displayed or was diagnosed with mental disorder or psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder (PTSD) were provided appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Specifically, one resident who was diagnosed with mental disorders and post-traumatic stress disorder experienced interactions with staff that caused them undue stress. Resident identifier: 28.

Findings include:

Resident 28 was admitted to the facility on [DATE REDACTED] with diagnoses which included spinal stenosis, intervertebral disc degeneration lumbar region, anxiety disorder, major depressive disorder, post-traumatic stress disorder, somatization disorder, and wedge compression fracture of T11-T12 vertebra.

On 1/27/25 at 9:45 AM, an interview was conducted with resident 28. Resident 28 stated they felt staff continually harassed and threatened them into moving rooms. Resident 28 stated the previous Administrator would threaten them on a daily basis and they would worry about it all day. Resident 28 stated they had a sensory processing disorder and they could not handle having people come in and out of their room, loud noises, or lots of visitors. Resident 28 stated they experienced a complete autistic meltdown and was in the fetal position and cried when they had a roommate that was loud and always had visitors. Resident 28 stated

they were moved to a different room about a year ago and they had cried, begged, and pleaded not to have to move. Resident 28 stated the Administrator and Director of Nursing (DON) came into their room about 2 weeks ago and stated they would have to move rooms or have a roommate and that this caused them stress and trauma and that, I was in a state of constant anxiety. Resident 28 stated they were now working to get approval to have a private room and that their therapist already wrote a detailed letter on why they needed a private room.

On 1/28/25 at 5:45 PM, an interview was conducted with resident 28 and her family member. The family member stated that resident 28's needs were not being met by facility staff and it felt like the facility administration was trying to upset her. The family member stated that administration came to resident 28's room and told her she was getting a roommate but she had the weekend before the resident would move in.

The family member stated administration told her the roommate was a fall risk and needed to be in a busier hallway. The family member stated administration told her the resident had alarms to keep her from falling.

The family member stated she told administration that would not work for resident 28. The family member stated facility staff were not aware of how to care for resident 28 because she required female CNA (Certified Nursing Assistants) to care for her because of her PTSD. The family member stated agency male CNAs had been assigned to care for her and resident 28 had to tell them males were not allowed to care for her. Resident 28 stated when a male staff came into her room it caused her excessive adrenaline which took her days to recover from. Resident 28 stated she had to buy her own Tylenol because she was told by the DON that they only supply a certain type and she needed a specific shape to be able to swallow them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0742 A concurrent observation was made of resident 28's door. The door had six signs taped on the outside of the door, which included: Level of Harm - Actual harm a. PLEASE BE QUIET WHEN IN THIS ROOM, THANKS!! Residents Affected - Few b. IMPORTANT NOTICE BED 'B' ONLY 1) NO VITAL SIGNS UNTIL AFTER BREAKFAST, PLEASE! 2) DO NOT WAKE RESIDENT TO OBTAIN VS [vital signs] @ ANY TIME!

c. Please Close Door UNTIL YOU HEAR IT CLICK Thanks!

d. ATTENTION STAFF!! Please keep in mind when assigned to this hall re: personal perfume/body spray/lotion, etc. - -There are residents with sensitivities to scents in this hall. - Please do not use air freshener in this hall!

e. KEEP DOOR CLOSED Please

f. IN THIS ROOM: Put on new gloves in front of resident, please & thank you!

On 2/5/25 at 2:38 PM, an interview and observation was made of resident 28. Resident 28 was visibly upset and stated the DON and Unit Manager (UM) came into the resident's room and took away their medications. Resident 28 was observed to lower her bed and pulled out a lock box that was placed under her bed and next to the night stand. Resident 28 stated that someone would have to move her bed and night stand to get to her lock box with medications. Resident 28 stated she administered her own medications because the nurse was always late which caused her to be anxious and feel awful. Resident 28 was observed to have a narcotic count sheet she filled out when she took her medications.

Resident 28's medical record was reviewed 1/27/25 through 2/6/25.

A Quarterly Minimum Data Set (MDS) Assessment, dated 1/2/25, indicated a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 13 to 15 indicated cognition was intact.

A Physician/Practitioner Note, dated 1/30/25 at 2:21 PM, indicated, .[Resident 28] has PTSD, anxiety, and major depressive disorder. [Resident 28] states that [Resident 28's] symptoms have been exacerbated by being told that [Resident 28] was going to share a room and possibly change [Resident 28's] current room. [Resident 28] states that [Resident 28's] symptoms have been exacerbated by being told that [Resident 28] is going to share a room and possibly change [Resident 28's] current room. [Resident 28] states that this has made [Resident 28] more depressed and made it more difficult for [Resident 28] to sleep. [Resident 28] complains of increased anxiety and constant worry. [Resident 28] is currently calm and cooperative during

this exam .The resident states that [Resident 28] had a hard time switching rooms previously and is worried that switching rooms again or having to have [Resident 28's] roommate will exacerbate things even more . Plan: .At this time the resident would benefit from having [Resident 28's] own private room however encourage the resident to meet with behavioral health to take [sic] about coping mechanisms so that the resident could adjust to changes .

A SS [Social Services] Quarterly & Annual Note, dated 10/1/24 at 3:07 PM, indicated, .Pt [patient] will make statements that staff are not being careful enough, trying to cause [resident 28] harm as they 'don't understand my sensory disorder' and even the littlest touch or unintended bump [resident 28] believes will cause [resident 28] permanent harm.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0742 The Care Plan indicated, The resident has a mood problem DX of Somatic symptom disorder per PASRR [Preadmission Screening Resident Review] level II. [Resident 28] has voiced multiple concerns about Level of Harm - Actual harm [Resident 28's] care, roommates, interactions with the staff, the environment. [Resident 28] states [Resident 28] has a 'sensory processing disorder' that makes [Resident 28] ultra sensitive to noise, smell, taste, ect. Pt Residents Affected - Few will make statements that staff are not being careful enough, trying to cause [Resident 28] harm as they don't understand my sensory disorder and even the littlest touch or unintended bump [Resident 28] believe will cause [Resident 28] permanent harm. Date Initiated: 04/18/2022 Revision on: 06/11/2024. It further indicated

a Goal of, [Resident 28] will have improved mood state e/b [as evidenced by] verbalizes satisfaction with [Resident 28's] stay at the facility through next review. Date Initiated: 04/18/2022 Revision on: 12/30/2024 Target Date: 04/13/2025. Interventions included, Administrator has approved a private room for [Resident 28] unless it is absolutely necessary to put a room mate in [Resident 28's] room. Date Initiated: 04/28/2023 Revision on: 07/19/2023. Assist the resident, family, caregivers to identify strengths, positive coping skills and reinforce these. Date Initiated: 04/18/2022. Remind staff to be very careful and not touch or bump [Resident 28's] bed. Date Initiated: 06/10/2024. [Resident 28] demonstrates a behavior of frequently complaining that staff are not being careful enough, trying to cause [Resident 28] harm as they don't understand my sensory disorder and even the littlest touch or unintended bump [resident 28] believe will cause [Resident 28] permanent harm. Date Initiated: 02/16/2024. [Resident 28] has a reminder sign on [Resident 28's] privacy curtain asking resident's to ask permission to go beyond the curtain. [Resident 28] has requested this sign. Date Initiated: 06/11/2024. [Resident 28] has multiple reminder signs on [resident 28's] door and on [resident 28's] armoire, at [resident 28's] request, all with specific requests. Date Initiated: 01/20/2023 Revision on: 06/11/2024. Staff should not enter [Resident 28's] room unless they hear [resident 28] respond to come in. Date Initiated: 06/10/2024.

On 1/29/25 at 9:25 AM, an interview was conducted with RN 2. RN 2 stated resident 28 required a female CNA to care for her and had been scheduled a male CNA which caused her distress. RN 2 stated she cared for resident 28 as a CNA when a male was assigned to her or another CNA assigned to another hall cared for her. RN 2 stated the facility was unable to provide resident 28 with type of Tylenol she was able to swallow so resident 28 had to buy her own.

On 2/4/25 at 9:11 AM, an interview was conducted with the Lead Certified Nurse Assistant (CNA). The Lead CNA stated resident 28 did not want any staff in resident 28's room and that resident 28 did not want males to go in resident 28's room because resident 28 had PTSD with males.

On 2/4/25 at 3:38 PM, an interview was conducted with CNA 6. CNA 6 stated that resident 28 did not allow her to go in their room and provide cares.

On 2/5/25 at 1:16 PM, a telephone interview was conducted with the Resident Advocate (RA). The RA stated

a discussion occurred in the morning meeting that a resident needed to moved to the 400 hall and resident 28's room was the only room that had a bed available, so resident 28 was asked to move rooms, but resident 28 absolutely refused to move or have a roommate. The RA stated resident 28 had somatizing disorder and PTSD and feared that any movement or bump would break resident 28's back, so this caused really bad anxiety and fixation on their back being broken.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0742 On 2/5/25 at 2:41 PM, an interview was conducted with the DON. The DON stated resident 28's medications were taken out of her room to satisfy a 2-lock rule for narcotics and that he told resident 28 that they were Level of Harm - Actual harm going to hold onto the medications until they bought a locked cabinet, but that they should be returned before

the next doses were due. The DON stated resident 28 said that would work for them. The DON stated Residents Affected - Few resident 28 would get panic attacks and sets them back a lot with the smallest changes and that they cannot move their room or put a roommate in with them because of it. The DON stated he knew he would get push back when resident 28 was asked to move but they were trying to do what was best for the other resident.

On 2/5/25 at 2:53 PM, an interview was conducted with the Administrator. The Administrator stated he talked to resident 28 about moving rooms or getting a roommate approximately 2 weeks ago but resident 28 did not want to do either option. Resident 28 called the State Ombudsman and the Department of Health and Human Services when this occurred and then he received a phone call from both entities, and he ended up asking a different resident to move from hall 400 to accommodate the facility's need so resident 28 did not need to move rooms or have a roommate. The Administrator stated that was his first interaction with resident 28. The Administrator stated when he talked to resident 28, [resident 28] was not having any of that and that resident 28 was crying and visibly upset. The Administrator stated the staff did warn him that resident 28 was not going to like being asked to do this and that resident 28 was very difficult but staff did not provide any more health information about why resident 28 would react that way. The Administrator stated resident 28 stated that they had mental health issues and did not want to talk to us about it. The Administrator stated resident 28 was upset about this incident for about 1 to 1-1/2 weeks.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30563 potential for actual harm Based on interview and record review, it was determined that for 1 of 33 residents, that the facility did not Residents Affected - Few ensure that the resident's drug regimen was adequately monitored. Specifically, a resident was administered

a medication used to treat hypertension when the resident's blood pressure was outside of parameters set by a physician's order. Resident Identifier: 3

Findings Include:

Resident 3 was admitted to the facility on [DATE REDACTED] and readmitted after hospital stay on 12/27/24 with diagnoses which included infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, Methicillin-resistant Staphylococcus aureus, end stage renal disease, dialysis, surgical

after care on circulatory system, diabetes mellitus, Alzheimer's disease, and osteoarthritis.

Resident 3's medical record was reviewed 1/27/25 and 2/6/25.

A physician's order dated 12/28/24 revealed Metoprolol Succinate ER [extended release] Oral Tablet Extended Release 24 Hour 50 MG [milligrams] (Metoprolol Succinate) Give 1 tablet by mouth one time a day for blood pressure HOLD for sbp [systolic blood pressure] < [ less than] 105 or hr [heart rate] <55.

The Medication Administration Record (MAR) dated 1/1/25 revealed a blood pressure of 100/59 with a HR of 69. Metoprolol Succinate was administered with blood pressure below parameters.

On 2/6/25 at 1:39 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the Metoprolol should have been held with a blood pressure of 100/59.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30563 potential for actual harm Based on observation, interview and record review it was determined, for 2 of 33 sampled residents, that the Residents Affected - Few facility did not ensure that residents were free of any significant medication errors. Specifically, a resident on vancomycin (vanco) was not administered according to pharmacy and physician orders. In addition, laboratory (labs) were not completed according to pharmacy and physician's orders. Another resident was administered medication for low blood pressure and it was not documented as administered. Resident identifier: 3 and 32.

Findings include:

1. Resident 3 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses which included infection and inflammatory reaction due to other cardiac and vascular devices, Methicillin-resistant Staphylococcus aureus (MRSA), and end stage renal disease with dialysis.

Resident 3's medical record was reviewed 1/27/25 through 2/6/25.

Discharge order from the local hospital dated 12/27/24 revealed resident 3 was admitted on [DATE REDACTED]. An order revealed Vancomycin for four weeks after each hemodialysis. If there were any questions contact an specific Infectious Disease physician.

a. A nursing progress note dated 12/28/24 at 10:46 AM revealed, This nurse called to clarify IV Vancomycin orders. The pharmacist stated the dose to give now: Vancomycin 1.5g IV. The pharmacist also stated to get vancomycin levels before dialysis tomorrow morning. Once the results come back, the pharmacist stated to notify pharmacy for dosing instructions. Resident notified about new orders.

A nursing progress note and physician's order on 12/28/24 revealed a PICC or mildline was to be placed.

There was no physician's order for Vancomycin to be administered on 12/28/24 and there was no documentation in the December 2024 Medication Administration Record (MAR) that Vancomycin was administered.

b. There was a physician's order dated 12/29/24 to obtain a vanco trough level. The level was returned to

the facility on [DATE REDACTED] revealed it was 31.7 The nurse documented in a nursing note that the physician and pharmacy was contact. The nurse documented the pharmacist instructed to hold the dose on 12/29/24 and draw another trough on 12/31/24.

c. On 12/31/24 a form titled Notification of Order Change(s) Made revealed the previous order was Vancomycin 1.5grams (gm)/300 milliliters (ml) IV once daily on dialysis days after dialysis. The new order was Vancomycin 1 gm/200ml IV once daily on dialysis days after dialysis over 1 hour. The labs to be draws were vancomycin level 1/3/25 pre dialysis. The form finished with please call pharmacy with results prior to administering dose.

The laboratory results dated [DATE REDACTED] revealed hand written documentation to give 1.5gm/200ml after dialysis, redraw trough on 1/3/25 before dialysis and call pharmacy for dosing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0760 [It should be noted that the doses were different from the laboratory form and notification of order change. In addition, vancomycin was not administered after dialysis on 1/1/25 and 1/3/25 which was documented on the Level of Harm - Minimal harm or notification of orders changes made.] potential for actual harm

A nursing note dated 1/1/25 revealed that IV vancomycin given on 12/31/24. Residents Affected - Few According to the physician's orders and December MAR there was no Vancomycin administered and no documentation of what doses were administered.

d. A nursing note dated 1/2/25 revealed called pharmacy to confirm vanco trough timing. Per pharmacist vanco trough was to be drawn 2 hours after dialysis then call pharmacy for dosing.

On 1/3/25 a Notification of Order Change(s) Made revealed vancomycin trough on 1/3 resulted in 22.6 and patient did not have dialysis 1/3. The new orders were to hold vancomycin medication and nurse ordered trough before patient next dialysis on 1/6 in the morning.

A nurses note dated 1/4/25 revealed Pharmacist called asking about vanco trough from yesterday. The nurse looked through nursing notes and found resident did not go to dialysis yesterday and trough was not drawn. The Pharmacist stated that it was okay for resident to not have IV vancomycin today 1/4/25 and 1/5/24 due to not being able to clear the vanco from not having dialysis. Pharmacist gave order to draw vancomycin trough levels before dialysis on 1/6/25.

e. A physician's progress note dated 1/6/25 and signed by the physician on 1/7/25 at 6:15 PM revealed Later in the evening, there was an issue with her vancomycin dosing, unable to ascertain her vancomycin level at the moment but needing a vancomycin dose after dialysis today. She was given 1 g of IV vancomycin based on prior dose of 1.5 g, with emphasis to obtain vancomycin level as soon as possible so as to allow proper dosing.

A nursing note dated 1/7/25 at 2:07 AM reveled that there was an order for vanco trough on 1/6. There were no results for the day and the night shift nurse called the physician because the pharmacy would not order a dose without a vanco level. The physician gave an order for a 1 time dose of Vanco 1 gram/200ml normal saline over 1 hour via PICC. The dose was administered at 7:45 PM on 1/6/25.

A nursing note dated 1/7/25 at 4:44 PM revealed, vanco trough results were 24.3. The pharmacy recommended to hold vanco 1/8 and redraw on 1/9.

A Nurse Practitioner (NP) dated 1/7/25 revealed, [Resident 3] was started on Vanco, 12/20, several days of no dose given related to high vanco trough levels. Recommend 21 days of Vanco. If issues continue with coordinating labs, discussed with nursing changing to oral medication. Her right arm remains with stitches, slightly pink.

f. A nursing note dated 1/9/25 at 1:06 PM revealed, this nurse called the lab to receive stat, random vanco level which was 17.8 and pharmacist would figure out the dose and send it to the facility.

A nursing note on 1/9/25 revealed the vanco was received from the pharmacy and it was to be administered

on 1/10/25 after dialysis. There was a physician's order and it was documented as administered on the January 2025 MAR.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0760 Nursing progress note from 1/11/25, 1/12/25 and 1/12/25 revealed resident finished IV Vanco for sepsis, resident finished regime of IV vanco. Level of Harm - Minimal harm or potential for actual harm A physician's progress note dated 1/13/25 revealed resident was getting ongoing vancomycin and finishing course today. Residents Affected - Few g. An NP progress note dated 1/14/25 revealed, no labs or any vanco over the weekend for unknown reasons. The note further revealed to continue vanco for 2 more weeks per Infectious Disease physician.

The physician wanted to have vanco after her dialysis with troughs completed on Friday and Wednesday. Would recommend going to oral antibiotics if this does not get followed.

An alert note dated 1/14/25 revealed new order for a random vanco trough.

A nursing note dated 1/15/25 at 12:05 AM revealed, resident had finished the course of IV vanco. At 5:04 AM, resident had been off vanco for multiple days. Random vanco level drawn. At 9:03 AM, vanco level was 13.5.

The laboratory results for revealed hand written documentation ATTN [attention]: Pharmacist .1/15 call pharm to dose vanco give today after dialysis initialed by the NP.

A Notification of Order Change(s) Made dated 1/15/24 revealed new order nurse will infuse Vancomycin IV 1 gram after dialysis today. Nurse ordered a vancomycin level on 1/17 before dialysis.

Administered Vanco according to the January 2025 MAR on 1/15/25.

h. On 1/17/25 a laboratory form was signed by the physician on 1/20/25. It was hand written MD notified, pharmacy notified vanco dose was to be held. The random level was 21.5 which was high.

Nursing progress notes revealed the vancomycin dose were held on 1/17/25, 1/18/25 and 1/19/25.

i. On 1/20/25 at 3:33 PM a nurses note revealed, vanco trough draw was 9.6. Pharmacy ordered vancomycin 750/150 ml to be administered. There was no physician's order or documentation in the MAR that the Vancomycin had been administered.

j. On 1/22/25 at 10:44 AM a nurses note revealed, vanco level was faxed to pharmacy and NP. Pharmacy was called and lab was reported. Another nurses note dated 1/22/25 at 3:44 PM, revealed the nurse attempted to call the pharmacy 2 or 3 times. Phones were acting weird and unable to get to the pharmacy.

The direct line to the pharmacist went straight to voice mail.

A nurses note dated 1/23/25 at 10:30 AM that the pharmacy faxed to give IV vanco 750 mg today.

The next administered dose was on 1/23/25 which was 750 mg/150ml.

There was a laboratory form dated 1/24/25 which was signed by the physician on 1/28/25 with no orders.

A nurses note dated 1/25/25 at 9:31 PM revealed, resident finished with IV vancomycin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0760 On 1/29/25 at 2:08 PM a nurses note revealed the NP ordered to remove the midline.

Level of Harm - Minimal harm or On 1/29/25 at 9:35 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated resident 3's potential for actual harm vancomycin dosing and trough were not drawn according to physicians orders. RN 2 stated the physician had to guess what the dosing was because there was not a trough drawn. RN 2 stated the physician had to Residents Affected - Few give random orders for vancomycin and hope for the best.

On 1/30/25 at 1:00 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated if a resident was admitted with orders for vancomycin, those orders needed to be put into the resident medical record. LPN 2 stated if a resident was receiving dialysis then a trough level was obtained before dialysis and sent to the laboratory stat. LPN 2 stated the pharmacy and physician got the laboratory results and determined the dose for that day and when to draw the next trough. LPN 2 stated all medications needed to have an order and a progress note. LPN 2 stated there was no concern with resident 3's vancomycin administration or obtaining trough levels.

On 1/30/25 at 1:30 PM, an interview was conducted with RN 1. RN 1 stated if a resident was on vancomycin,

a trough needed to be obtained after the 4th Vancomycin dose. RN 1 stated the pharmacy dosed vancomycin for resident who were were on dialysis. RN 1 stated based on the trough, the pharmacy determine the dose. RN 1 stated resident 3 was on vancomycin because she had a fistula infection. RN 1 stated resident 3 had surgery to removed the infection and was ordered vancomycin when she returned from

the hospital. RN 1 stated resident 3 had troughs drawn early in the morning and usually received the results

the same day. RN 1 stated she called the pharmacy with the trough results and the pharmacy provided the dose resident 3 needed. RN 1 stated resident 3 was to be administered vancomycin on her dialysis days. RN 1 stated orders for the Vancomycin were entered into resident 3's medical record and into her MAR to be marked off when it was administered.

On 2/3/25 at 10:30 AM, an interview was conducted with Physician 1. Physician 1 stated he was aware resident 3 was receiving vancomycin for an infection. Physician 1 stated vancomycin needed to be administered after dialysis because it was removed by dialysis. Physician 1 stated there were challenges with getting the trough levels lined up correctly. Physician 1 stated at times, he had to make his best estimate

on the dose to administer. Physician 1 stated with kidney disease and dialysis it made the dosing for vancomycin easier. Physician 1 stated elevated vancomycin levels could result in kidney damage but since resident 3 was on dialysis it was not a big concern. Physician 1 stated the main thing was to get the infection out of resident 3. Physician 1 stated resident 3's vancomycin should have been administered every other day

after dialysis. Physician 1 stated he knew there were some difficulties with the lab but resident 3's dosing should not have been that difficult. Physician 1 stated the dose could have been based on the resident weight. Physician 1 stated the trough needed to be obtained to ensure there was a therapeutic level. Physician 1 stated a normal trough level was 15-20. Physician 1 stated resident 3's vancomycin levels were not toxic.

On 2/3/25 at 1:11 PM, an interview was conducted with LPN 1. LPN 1 stated he knew that resident 3 was on vancomycin for a while. LPN 1 stated the vancomycin was administered on dialysis days after dialysis. LPN 1 stated resident 3 had troughs drawn before each dose or at least once per week. LPN 1 stated the nurses received the results and discussed with pharmacy on how much to administer. LPN 1 stated he did not think there were any concerns with obtaining laboratory values for resident 3.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0760 On 2/3/25 at 1:31 PM, an interview was conducted with the Director of Nursing (DON). The DON stated for residents who required Vancomycin, there should be a trough drawn every other dose. The DON stated if a Level of Harm - Minimal harm or resident was on dialysis, the pharmacy managed their Vancomycin dosing. The DON stated resident 3 was potential for actual harm administered the vanco after dialysis and then a trough was drawn before the next dose. The DON stated dosing vanco was more tricky with dialysis. The DON stated the nurse needed to enter physician's orders Residents Affected - Few according to what the pharmacy instructed. The DON stated when Vancomycin was administered there needed to be a signed physician's order and the nurse needed to initial when it was administered in the MAR. The DON stated the physician signed the orders. The DON stated resident 3 came from the hospital with a 21 day vancomycin regimen, so resident 3 should be administered the dose for 21 days based on the trough levels.

On 2/4/25 at 9:16 AM, an interview was conducted with Regional Nurse Consultant (RNC) 1. RNC 1 went over the above information with the surveyor. RNC 1 stated hospital orders were 3 weeks to have Vancomycin finished on 1/23/25. RNC 1 stated there were physician's orders on the form titled Notification of Order Change and on the laboratory results form. RNC 1 stated the DON was provided emails from the pharmacy for orders of Vancomycin and troughs. RNC 1 stated there was no physician's order for the Vancomycin administered on 12/28/24. RNC 1 stated on 1/6/25 there was no laboratory results. RNC 1 stated the trough sample not picked up by lab on 1/6/25. RNC 1 stated the sample had been out to long to test so a redraw was done on 1/7/25. RNC 1 stated there was a discussion around 1/10/24 that the Unit Manager (UM) was going to contact the infectious disease (ID) physician regarding discontinuing the Vancomycin. RNC 1 stated there was no documentation regarding if the UM contacted the ID. RNC 1 stated

a trough was drawn on 1/13/25 and signed by the physician on 1/14/25. RNC 1 stated there was no documentation the physician was contacted on 1/13/25. RNC 1 stated there was no physician's order for the trough on 1/20/25. RNC 1 stated for the labs on 1/22/24, the phones were having problems so the nurse contacted the DON. RNC 1 stated she was not sure if the DON contacted the physician or the pharmacy. RNC 1 stated that a trough was completed on 1/24/25 and the laboratory form was signed by the physician

on 1/28 with no orders. RNC 1 stated after looking through resident 3's medical record regarding Vancomycin she had created a performance improvement plan.

On 2/4/25 at 11:58 AM, a follow up interview was conducted with RNC 1. RNC 1 provided the Notification Orders Change Made dated 12/31/24 which revealed a new order to provide Vancomycin on dialysis days

after dialysis. RNC 1 stated according to those orders resident 3 should have been administered Vancomycin Monday, Wednesday and Fridays after dialysis and recheck on 1/6/25. RNC 1 stated resident 3 was not administered Vancomycin on 1/1/25 or 1/3/25.

43212

2. Resident 32 was admitted to the facility on [DATE REDACTED] with diagnoses that included end stage renal disease, acquired absence of left leg below the knee, dysphagia, sleep related hypoventilation, cirrhosis of the liver, osteomyelitis of the lumbar spine.

Resident 32's medical record was reviewed between 1/27/25 and 2/6/25.

Resident 32's physician orders dated 7/15/24 revealed, Midodrine HCl [hydrochloride] Oral Tablet 5 MG [milligram], Give 5 mg by mouth every 24 hours as needed for low b/p [blood pressure] SBP [systolic blood pressure] less than 130.

A review of resident 32's MARs revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0760 a. The December 2024 MAR revealed administration of Midodrine 5 mg on 12/31/24 at 7:44 AM.

Level of Harm - Minimal harm or b. The January 2025 MAR revealed administration of Midodrine 5 mg on 1/3/25 at 7:10 AM, 1/29/25 at 6:17 potential for actual harm AM, and 1/31/25 at 9:52 AM.

Residents Affected - Few Resident 32's progress notes revealed:

a. On 12/31/24 at 7:44 AM, an orders-administration note revealed, Midodrine HCl Oral Tablet 5 mg; Give 5 mg by mouth every 24 hours as needed for low b/p SBP less than 130. Midodrine given per dialysis request. bp 90/60.

b. On 1/3/25 at 7:10 AM, an Orders-administration note revealed, Midodrine HCl Oral Tablet 5 mg; Give 5 mg by mouth every 24 hours as needed for low b/p SBP less than 130.

c. On 1/20/25 at 4:00 PM, a nursing progress note revealed, Resident is hypotensive during dialysis even with prn [as needed] medications. tolerated HDTX [hemodialysis treatment] with no other complications.

d. On 1/29/25 at 6:17 AM, an Orders-administration note revealed, Midodrine HCl Oral Tablet 5 MG; Give 5 mg by mouth every 24 hours as needed for low b/p SBP less than 130. given to dialysis RN [registered nurse] due to low b/p during treatment.

Dialysis communication documentation returned with resident 32 revealed:

a. On 12/31/24, Patient condition or events during/post dialysis: The patient tolerated HDTX w/o [without] complications.

b. On 1/3/25, Patient condition or events during/post dialysis: The patient tolerated HDTX w/o complications.

c. On 1/20/25, Pt [patient] is hypotensive during the tx [treatment] even w [with]/taking PRN med [medication] and tolerated HDTX w/o other complication. (systolic BP 90'ish)

[It should be noted there was no medication administration documented on resident 32's MAR.]

d. On 1/29/25, Pt was hypotensive for 2 hrs [hours] but tolerated HDTX without other complications. (8-10 AM). [Resident 32] was hypotensive even taking PRN med Midodrine.

On 1/28/25 at 3:00 PM, an interview was conducted with LPN 1 who stated he did not provide resident 32 with Midodrine every day, only if resident 32's blood pressure dropped during dialysis. LPN 1 stated if resident 32's blood pressure dropped while receiving dialysis, the dialysis nurse called and requested the nurse bring the medication down and administer it. LPN 1 stated after resident 32 finished dialysis, he returned to the resident area with a report stating what his blood pressure was. LPN 1 stated he had not provided Midodrine to resident 32. LPN 1 stated the Certified Nursing Assistants [CNA]s completed vital signs on residents and gave the results to the nurse on duty. LPN 1 stated if there was a question about a blood pressure he would check it himself. LPN 1 stated when, on 1/23/25, resident 32's blood pressure was 110/55 mmHg [millimeters of mercury] and he asked resident 32 how he was feeling before providing the medication.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0760 On 1/28/25 at 3:18 PM, an interview was conducted with the DON who stated resident 32 was a dialysis patient and the order for Midodrine was for dialysis. The DON stated the nurses looked at the resident's Level of Harm - Minimal harm or dialysis communication form and talked with the resident before providing Midodrine. The DON stated, potential for actual harm [resident 32] knows how he feels. The DON stated on non-dialysis days, resident 32's blood pressure was not checked so staff went by how the resident stated they felt. The DON stated the order for Midodrine was Residents Affected - Few not an every day order. The DON stated if the dialysis center requested the Midodrine for resident 32, the nurse would provide it and document it in a progress note.

On 2/5/25 at 8:47 AM, an interview was conducted with the Dialysis Registered Nurse [DRN] who stated resident 32's vital signs were kept in her computer system in dialysis. The DRN stated if resident 32's blood pressure was low, she would call upstairs to the nurse on duty and request they bring a Midodrine down to resident 32. The DRN stated the nurses were 100% responsive administering Midodrine when she called and resident 32 was 100% compliant in taking it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30563 potential for actual harm Based on interview and record review it was determined, for 1 of 33 sampled residents, that the facility did Residents Affected - Few not provide or obtain timely laboratory (lab) services to meet the needs of its residents. Specifically, a resident's vancomycin trough was not obtained timely. Resident identifer: 3.

Findings include:

Resident 3 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses which included infection and inflammatory reaction due to other cardiac and vascular devices, Methicillin-resistant Staphylococcus aureus (MRSA), and end stage renal disease with dialysis.

Resident 3's medical record was reviewed 1/27/25 through 2/6/25.

There was a physician's order dated 1/6/25 for vanco trough level before dialysis.

A review of the medical record revealed no vanco trough results.

A physician's progress note dated 1/6/25 and signed by the physician on 1/7/25 at 6:15 PM revealed Later in

the evening, there was an issue with her vancomycin dosing, unable to ascertain her vancomycin level at the moment but needing a vancomycin dose after dialysis today. She was given 1 g [gram] of IV [intravenous] vancomycin based on prior dose of 1.5 g, with emphasis to obtain vancomycin level as soon as possible so as to allow proper dosing.

A nursing note dated 1/7/25 at 2:07 AM reveled that there was an order for vanco trough on 1/6. There were no results for the day and the night shift nurse called the physician because the pharmacy would not order a dose without a vanco level. The physician gave an order for a 1 time dose of Vanco 1 gram/200ml [milliliter] normal saline over 1 hour via PICC. The dose was administered at 7:45 PM on 1/6/25.

A nursing note dated 1/7/25 at 4:44 PM revealed, vanco trough results were 24.3. The pharmacy recommended to hold vanco 1/8 and redraw on 1/9.

On 1/29/25 at 9:35 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated resident 3's vancomycin dosing and trough levels were not drawn according to physicians orders.

On 2/4/25 at 9:16 AM, an interview was conducted with Regional Nurse Consultant (RNC) 1. RNC 1 stated

on 1/6/25 there was no laboratory results. RNC 1 stated the trough sample was not picked up by lab on 1/6/25. RNC 1 stated the sample had been out to long to test so a redraw was done on 1/7/25. RNC 1 stated

after looking through resident 3's medical record regarding Vancomycin she had created a performance improvement plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 43212 potential for actual harm Based on observation, interview and record review it was determined, for 5 of 33 sampled resident, the Residents Affected - Some facility did not provide food prepared by methods that conserve flavor and appearance or provide food and drink that was palatable, attractive, and at an appetizing temperature. Specifically, there were multiple complaints from residents about palatable and cold food. There were observations of no plate warmers and there were resident complaints about cold food in the resident council minutes. Resident identifiers: 26, 28, 29, 33 and 34.

Findings include:

On 1/27/25 at 9:56 AM, an interview was conducted with resident 33 who stated breakfast and lunch were ok, but the dinner meal needed improvement. Resident 33 stated residents were getting a lot of sandwiches and hamburgers.

On 1/27/25 at 11:10 AM, an interview was conducted with resident 34 who stated the food was not always good. Resident 34 stated the evening meal was mostly sandwiches.

On 1/27/25 at 2:16 PM, an interview was conducted with resident 26. Resident 26 stated the food was not good. Resident 26 stated the scrambled eggs were smashed eggs and he did not like it.

On 1/27/25 at 9:45 AM, an interview was conducted with resident 29. Resident 29 stated the food was not warm. Resident 29 was observed to be eating breakfast. There was no warmer under the plate. Resident 29 stated they did not usually send the trays with the warmer. Resident 29 stated the other night she had warm food when her tray was sent with the warmer. Resident 29 stated she was told by kitchen staff that to use the warmers, it would take the facility staff more than 5 hours for each meal.

On 1/27/25 at 9:45 AM, an interview was conducted with resident 28. Resident 28 stated the food was delivered cold, often for dinner and on the weekends because the plate warmers were not being used. On 1/28/25 at 3:07 PM, a follow up interview was conducted with resident 28. Resident 28 stated the roasted turkey that was served at lunch was sliced deli meat. Resident 28 stated the pork and beef were so tough,

they could not be chewed. Resident 28 stated the meats were over cooked and vegetables were under cooked.

On 1/27/25 during the lunch meal service an observation was made of the hallway trays. There were no warmers under the plates on the trays.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0804 On 2/4/25 at 11:37 AM, an observation was made in the kitchen of [NAME] 1 preparing the lunch meal which consisted of meatballs in cream sauce, mashed potatoes with brown gravy, peas and carrots, a slice of Level of Harm - Minimal harm or bread and a cup of crushed pineapple. An observation was made of a stack of plate warmers on the food potential for actual harm preparation table near where the meal was being plated. An interview was conducted with [NAME] 1. [NAME] 1 stated he had already heated up the plate warmers and they were ready to be used for the lunch Residents Affected - Some meal. [NAME] 1 picked up a plate warmer and stated, here, test it. The surveyor touched the plate warmer and it warm to the touch. At 11:51 AM, [NAME] 1 was observed to put a scoop of mashed potatoes on the plate, followed by a small ladle of brown gravy. A scoop of peas and diced carrots was put on the plate, then 3 meatballs with a small amount of cream sauce. A slice of white bread was put on top of the food on the plate. Some plates were covered without a plate warmer on the bottom. Those plates were put on a kitchen rack, other plates were put on a plate warmer, then covered the plates with a dome and put in a meal cart. It was noted that several meals were plated without plate warmers and put on the kitchen rack before meals were placed into the hall carts and sent out.

On 2/4/25 at 12:03 PM, the kitchen rack was wheeled into the dining room.

On 2/4/25 at approximately 12:05 PM, the first hall cart left the kitchen for the 400 hallway, followed by the 100 hall cart. The 300 hall cart was the last to leave the kitchen.

On 2/4/25 at 12:14 PM, a test tray was requested. At 12:15 PM the meal was put onto the 300 hall cart as it left the kitchen. An observation was made that the 100 hall cart had not been picked up when the 300 hall cart left for the hallway.

On 2/4/25 at 12:24 PM, the test tray was removed from the 300 hall cart.

On 2/4/25 at 12:25 PM, the following observations were made of the lunch meal which had a variation of color on the plate and a nice presentation:

a. Meatballs with cream sauce-132.6 degrees Fahrenheit. The meatballs were well seasoned with a pleasing flavor, and were warm to the taste.

b. Mashed potatoes with brown gravy-147.4 degrees Fahrenheit. The potatoes were warm to the taste, soft and a pleasant flavor.

c. Peas and diced carrots-132.4 degrees Fahrenheit. The vegetables were easy to chew, not over cooked, and not mushy.

d. Slice of white bread-was dry and stale to the taste.

e. Crushed pineapple-47.8 degrees Fahrenheit. The pineapple tasted like canned pineapple.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0804 On 2/6/25 at 9:14 AM, an interview was conducted with the Dietary Manager (DM) who stated plate warmers were used for all meals unless the meal was a cold meal. The DM stated the plates were stored in the plate Level of Harm - Minimal harm or warmer between meals, and at approximately 11:20 AM, the cook would start warming up the plate holders potential for actual harm for the meal. The DM stated the majority of cold food complaints came from the weekend. The DM stated the cook who worked on the weekends was not using the plate warmers because of laziness. The DM stated he Residents Affected - Some and the Administrator had been checking in on the weekends to ensure the cook was using the plate holders. The DM stated the cook took the temperature of the food right after it came out of the oven and

before it went on the steam table. The DM stated as long as the steam table was on, the food should stay hot and could stay there a while. The DM stated he had attended resident council when he was invited. The DM stated if he did not go, the information from the resident council was passed on to him by another staff member. The DM stated after receiving a resident complaint, he would go to visit with the resident. The DM stated he also attended the quarterly meetings with residents to follow-up on any complaints they might have or address any concerns. The DM stated he wanted to make sure the residents were satisfied. The DM stated he also liked to meet with resident's family members as he was able to find things out that the resident might not tell him, such as dislikes or preferences.

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A review of the facility's resident council meetings revealed:

a. August 2024: .Action Items-Grievances to Follow-Up -cold food-ongoing issue . Dietary: -cold food .

b. September 2024: .OLD BUSINESS .cold food-educated weekend staff . Dietary: cold veggies on Sept [September] 25th lunch .Concern/Problem Cold Veggies on Sep [September] 25th lunch in dining room . Resolution ok .

c. November 2024: .Action Items-Grievances to Follow-Up .cold food .Dietary: Food cold on weekends + [and] weekdays .

d. December 2024: .Action Items- Grievances to Follow-Up .Food temp [temperature] .Dietary: -not reading meal tickets -Food temp- use plate warmers .

e. January 2025: .Concern/Problem Report of cold food .

30563

48709

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30563

Residents Affected - Few Based on observation, interview and record review it was determined, for 2 of 33 sampled residents, that the facility did not ensure the facility provided each resident with food prepared in a form designated to meet their individual needs. Specifically, thickened beverages were not prepared according to the recipe. Resident identifiers: 2 and 4.

Findings include:

1. Resident 4 was admitted to the facility on [DATE REDACTED] with diagnoses which included dysphagia, intellectual disabilities and cognitive communication deficit.

Resident 4's medical record was reviewed 1/27/25 through 2/6/25.

A physician's order dated 6/24/24 revealed regular diet, pureed, nectar/mildly thick consistency.

2. Resident 2 was admitted to the facility on [DATE REDACTED] with diagnoses which included multiple sclerosis, dysphagia and cognitive communication deficit.

Resident 2's medical record was reviewed 1/27/25 through 2/6/25.

A physician's order dated 6/24/24 revealed Resident is on thickened liquids two times a day for dysphagia.

A physician's order dated 11/27/24 revealed regular pureed texture with nectar/mildly thick consistency.

A Speech Language Pathology (SLP) Discharge Summary dated 5/31/21 revealed no information regarding swallowing. Resident 2 was provided cognitive treatments.

On 1/27/24 at 11:58 AM, an observation was made of the lunch meal in the dining room. Resident 2 and resident 4 were observed in the dining room. Resident 4 and resident 2 were observed with beverages that were not thick.

On 1/27/25 at 12:32 PM, an interview was conducted with the Dietary Manager (DM). The DM stated the Dietary Aides (DA) thickened the liquids the day before. The DM stated the liquids provided to residents for lunch would have been made the night before so they thickened in the refrigerator.

An observation was made of DA 1 preparing thickened beverages. DA 1 stated she was not sure how big the cups were and she thought they were 4 ounces (oz). DA 1 was observed to ask DA 2 how big the glasses were and he stated 6 oz. DA 1 was observed to use 1 pump of liquid thickener for the 6 oz. DA 1 was observed to stir the liquid for about 10 seconds, placed a lid on it and wrote an N on it. DA 1 stated she then put the date and drinks into the refrigerator to use the next day.

The liquid thickener bottle was observed and revealed the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0805 a. Slightly thick use 1 pump for 6 oz of liquid

Level of Harm - Minimal harm or b. Mildly thick/nectar use 1 pump for 4 oz of liquid or 2 pumps for 8 oz of liquid potential for actual harm c. Honey thick 2 pumps for 4 oz of liquid and 4 pumps for 8 oz of liquid. Residents Affected - Few Follow usage chart. Dispense appropriate amount of [thickener] get into beverage. Stir briskly for 30 seconds.

It should be noted the beverages were made slightly thick and were not stirred for 30 seconds.

On 2/6/25 at 10:18 AM, an interview was conducted with the Director of Rehab (DOR). The DOR stated resident 4 was never provided SLP services while a resident at the facility. The DOR stated resident 2 was not provided services since 2021 and they were for cognition and not swallowing.

On 2/6/25 at 11:58 AM, an interview was conducted with SLP 1. SLP 1 stated mildly and nectar thick liquids were the same. SLP 1 stated residents with dysphagia and ordered mildly thick/nectar thick should be served thicker rather than thinner to prevent aspiration. SLP 1 stated mildly/nectar thick were similar textures to tomato juice. SLP 1 stated the facility staff should be following the instructions on the container. SLP 1 stated

the beverage needed to be mixed for one minute before serving.

43212

On 2/6/25 at 9:14 AM, an interview was conducted with the DM who stated the dietary aides had been trained on how to thicken the liquids for those residents who required thickened liquids. The DM stated the bottles of liquid thickener had a list on the bottle of how much of the thickener should go in depending on the quantity of liquid. The DM stated the dietary aide looked at the bottle of thickener before thickening the liquids to make sure the correct amount of thickener was used. The DM stated he did not know if the dietary aides could interpret what the consistency was supposed to look like. The DM stated if liquid was not thickened appropriately, it could result in a choking hazard to the resident or aspiration pneumonia. The DM stated he had not had any residents develop aspiration pneumonia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43212

Residents Affected - Some Based on observation and interview it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the reach in refrigerator were open to air and not labeled, food items in the walk in refrigerator were past the use-by date, frozen food in the walk-in freezer were open to air, food items in the kitchen were open to air, and the kitchen was unclean. Additionally, there were no test strips to ensure the sanitation bucket had the correct amount of sanitizer in it and the Dietary Manager (DM) was not wearing a beard guard while in the kitchen.

Findings include:

On 1/27/25 at 8:42 AM, an initial kitchen walk-through was conducted. The floors under the stove and oven were observed to have crumbs and food particles underneath, the microwave had a brown substance spilled inside, the top of the dish machine had crumbs on it. There was food splatter on the wall behind one of the food preparation tables, a mop head was on the floor under the steam table. The garbage was overflowing near the DM's desk, and there were no paper towels in the dispenser by the sink.

On 1/27/25 at 8:50 AM, observations were made in the food storage areas. In the reach-in refrigerator, there was no thermometer to confirm the temperature inside. A container of vegetable base was open and not covered. A dish of shredded cheese, covered in plastic wrap, was not labeled. Six separate cuts of meat were wrapped in plastic wrap but were not labeled and dated. Two packages of white cheese were not labeled, a package of yellow cheese was wrapped in plastic wrap and not labeled, a bag of [NAME]/cheddar cheese mix was open to air and not labeled, a bag containing boiled eggs was not labeled, a container of lemon juice had a use by date of 1/3/25, a container of sweet and sour sauce was open with no lid on it, and

a box of green peas was open to air. The reach-in freezer did not have a thermometer in it. The temperature outside the unit read -4 degrees Fahrenheit.

On 1/27/25 at 9:05 AM, the DM was observed to check the sanitation bucket. The DM obtained a testing strip and dipped it into the sanitation bucket. After holding in the water for a few seconds, the test strip revealed no result. The DM tried another strip with no result. The strips were for the dish machine. The DM stated the sanitation bucket was changed at 5:30 AM. The DM stated he did not have the correct strips to check the sanitation buckets citing budgetary constraints and not being allowed to order more strips.

On 1/27/25 at 9:09 AM, an observation was made of a food storage shelf above a food preparation area. A box of cornbread mix was open to air. A box of cream of wheat was open to air.

On 1/27/25 at 9:15 AM, an observation was made in the walk-in freezer. A box of chocolate chips was open to air and a box of frozen ravioli was open to air. In the walk-in refrigerator, 5 gallon jugs of fat free milk were found to be past the use by date of 1/22/25. In the dry storage room, cans of diced pears were not dated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0812 It should be noted that temperature logs had been completed for future dates and times for the storage areas

in the basement of the building, and there were several days on the dish machine temperature log that had Level of Harm - Minimal harm or not been completed. potential for actual harm

On 1/27/25 at 11:25 AM, an observation was made of [NAME] 1. [NAME] 1 was wiping down a food cart with Residents Affected - Some a rag from the sanitation bucket. [NAME] 1 stated he had just put fresh water into the bucket. [NAME] 1 checked the bucket again with the strips from the dish machine and obtained no reading.

On 1/27/25 at 11:54 AM, an interview was conducted with the DM who stated [chemical supplier] had not been to the facility for service since November 2024. The DM stated he was very restricted as to what he was allowed to order. The DM stated he gets in trouble when he orders from [chemical supplier]. The DM stated he was required to order supplies from another supplier. The DM stated he had ordered new thermometers for the reach in refrigerator, but had not yet received them.

On 1/27/25 at 2:11 PM, an interview was conducted with the DM who stated he conducted his own audits of

the kitchen each Monday. The DM stated he threw the milk away from the walk-in refrigerator, and had found

the thermometer in the reach in refrigerator which had fallen to the back behind food items.

On 2/4/25 at 11:37 AM, a second walk-through was conducted in the kitchen. In the reach-in refrigerator, a box of cookies was open to air. In the reach-in freezer, a box of peas and carrots was open to air. There was no thermometer in the reach-in freezer. On the shelf above one of the food preparation areas, a box of corn bread mix was open to air, a box of cream of wheat was open to air, a box of corn starch was open to air. Food crumbs were observed to be under the oven and stove.

On 2/6/26 at 8:57 AM, an observation was made of the food storage areas in the basement. The walk-in freezer was observed to have chocolate chip cookie dough open to air, a box of frozen peas was open to air,

a box of frozen broccoli was open to air, a box of dinner rolls was open to air. In the walk-in refrigerator, a large box of zucchini was found to be moldy.

On 2/6/25 at 9:14 AM, an interview was conducted with the DM who stated his expectation for food being placed back into the refrigerator or freezer after partial use was that it be labeled and dated. The DM stated

he was out a lot for the month of January so he was not checking the storage areas as frequently as he usually did. The DM stated the Regional Dietitian (RD) usually came to do monthly audits in the kitchen, but left last November so there had been no audits completed. The DM stated the consultant RD was the only dietitian he was working with. The DM stated the RD did her first audit on 2/4/25 and had not been informed

the regional RD was not with the company. The DM stated he had taken some disciplinary action against the kitchen staff for the lack of meeting expectations to make sure they know what they should be doing and were doing it. The DM stated for the aids, it was likely lack of knowledge, and stated for the cooks, it was laziness. The DM stated kitchen staff should be wearing standard attire in the kitchen which included a hairnet or hat, gloves when washing dishes, and changing gloves between handling different food items. The DM stated any time a staff member went past the yellow line in the kitchen, a hair net was required. The DM stated he still did not have the correct strips to check the sanitation buckets. The DM stated the consequence of not knowing if the sanitation bucket contained the right amount of sanitizer was there was a possibility of food bourne illness and cross contamination. The DM stated food in storage areas that was open to air did not last as long and the quality not as good.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30563

Residents Affected - Few Based on observation, interview and record review it was determined, for 3 of 33 sampled residents, that the facility did not maintain medical records on each resident that was complete; accurately documented; readily accessible; and systematically organized. Specifically, a resident's wound orders were not the same as the wound orders documented by the Wound Physician Assistant, Certified (PA-C) and resident shower sheets were not in their medical records. Resident identifiers: 3, 6, and 293.

Findings include:

1. Resident 6 was admitted to the facility on [DATE REDACTED] with diagnoses which included type 2 diabetes mellitus with hyperglycemia, major depressive disorder, generalized anxiety, scoliosis and chronic pain.

On 2/5/25 at 10:51 AM, an observation was made of resident 6's leg with the Wound PA-C and Registered Nurse (RN) 1. There were 2 dressings on his left lower extremity.

Resident 6's medical record was reviewed 1/27/25 through 2/6/25.

A current physician's order dated 1/24/25 revealed Wound to left lower leg: cleanse w/ [with] wound cleanser, apply collagen to open areas, cover w/ border foam. Change every other day et [and] prn [as needed]. every day shift every other day. According to the January 2025 Treatment Administration Record (TAR) the dressings were changed on 1/24/25, 1/26/25, 1/28/25 and 1/30/25, 2/1/25, 2/3/25, 2/5/25.

A progress note from the Wound PA-C revealed on 1/22/25 an order to Remove dressing (if applicable), cleanse wound per standard wound care protocol and apply the following order:

Apply to peri-wound: A&D ointment

Apply to wound bed: Collagen

Cover with: Ca Alg [Calcium Alginate]

Secure with rolled gauze

Treatment frequency QOD [every other day] and prn if soilked [sic] or dislodged dressing.

A progress note from the Wound PA-C revealed on 1/29/25 an order to Remove dressing (if applicable), cleanse wound per standard wound care protocol and apply the following order:

Location: Apply to peri-wound: A&D ointment

Apply to wound bed: Place collagen and covered Dressing on open wounds.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0842 Apply betadine to scabbeed [sic] areas

Level of Harm - Minimal harm or Cover with: rolled gauze potential for actual harm Secure with: N/A [not applicable] Residents Affected - Few Treatment frequency: QOD and PRN if soilked [sic] or dislodged dressing.

The Wound Nurse Progress Note dated 1/29/25 revealed the wounds were getting smaller.

On 2/5/25 at 9:17 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that

the Director of Nursing (DON) was the facility wound nurse. LPN 1 stated if he had any questions, then he asked the DON.

On 2/5/25 at 9:59 AM, an interview was conducted with the DON. The DON stated there was a wound specialist that came to the facility weekly.

On 2/5/25 at 10:01 AM, an interview was conducted with the Wound PA-C. The Wound PA-C came to the facility weekly and looked at the wounds with the nurse or the DON. The Wound PA-C stated she documented on the wound and provided new orders to nurse or DON and then her Medical Assistant sent her notes to the DON. The Wound PA-C stated resident 6 had a venous stasis ulcers on his left lower extremity. The Wound PA-C stated the order she provided on 1/22/24 was Scabbed area with betadine to try and dry up the scabs to fall off. The Wound PA-C stated as the venous stasis ulcer starts to heal, it will start to dry out so she wanted to have A&D ointment on the peri wound.

On 2/6/25 at 11:45 AM, an interview was conducted with the DON. The DON stated the physician's order that was on the TAR was not the same order as the Wound PA-C documented. The DON stated the orders needed to match.

2. Resident 3 was admitted to the facility on [DATE REDACTED] with diagnoses which included infection and inflammatory reaction due to other cardiac and vascular devices, end stage renal disease with dialysis, Methicillin-resistant Staphylococcus aureus, surgical after care following surgery on the circulatory system, diabetes mellitus and Alzheimer's disease.

On 1/27/25 at 2:47 PM, an interview was conducted with resident 3. Resident 3 stated she got showers once

a week but would like them twice a week.

Resident 3's medical record was reviewed 1/27/25 through 2/6/25.

The Lead Certified Nursing Assistant (CNA) provided forms titled Shower Sheet revealed resident 3 was showered on 12/4/24 and 12/18/24. There was a Shower Sheet for 12/21/24 which revealed resident 3 was

in the hospital. Resident 3 refused a shower on 1/4/25, 1/8/25 and 1/22/25. Resident 3 was showered on 1/11/25, 1/15/25 and 1/18/25. The forms were not in resident 3's medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0842 On 1/28/25 at 4:11 PM, an interview was conducted with the Lead CNA. The Lead CNA stated if a resident refused a shower, then the resident signed a Shower Sheet along with the nurse and CNA. The Lead CNA Level of Harm - Minimal harm or stated Shower Sheets were completed after each shower and then provided to her or the medical records potential for actual harm staff member. The Lead CNA stated the shower sheets were then put into a file on her computer.

Residents Affected - Few On 2/4/25 at 12:52 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there was a shower sheet that was completed by CNA's. The DON stated CNA's documented showers and refusals in the tasks section and on a Shower Sheet. The DON stated the Shower Sheet went to the Lead CNA and were uploaded into a file on her computer. The DON stated the Shower Sheets were not added to

the resident's medical record.

50200

3. Resident 293 was admitted to the facility on [DATE REDACTED] with diagnoses which included displaced intertrochanteric fracture of left femur, other toxic encephalopathy, major depressive disorder, muscle weakness, and need for assistance with personal care.

On 1/27/25 at 10:24 AM, an observation and interview were conducted with resident 293. Resident 293 was observed to be wearing a hospital gown and had a hospital identification bracelet on his right arm with a date of service of 1/14/25. Resident 293 stated that he had not received a shower since he arrived at the facility and had to give himself a whores bath. Resident 293 stated that a whores bath consisted of him washing his armpits and genitals with some bottled water that he had. Resident 293 stated that he had tipped over his urinal the night before and had soaked himself and his bed sheets with urine.

A review of resident 293's medical record was reviewed 1/27/25-2/6/25.

Resident 293 was scheduled to receive showers on Mondays and Thursdays.

The tasks section of resident 293's medical record revealed that he received a shower on 1/27/25 at 12:35 PM.

A review of resident 293's shower sheets revealed the following:

a. On 1/16/25 a shower was refused

b. On 1/20/25 there was no shower sheet provided

c. On 1/23/25 a shower sheet documented that resident 293 received a shower the previous morning. There was no documentation to confirm this.

d. On 1/27/25 a shower was completed

There was no other documentation to confirm additional showers were provided to resident 293. There were no shower sheets located in resident 293's medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0842 On 1/28/25 at 3:48 PM, an interview was conducted with the Lead CNA. The [NAME] CNA stated resident 293 had a shower on 1/27/25. The Lead CNA stated resident 293 was scheduled for showers on Mondays Level of Harm - Minimal harm or and Thursdays. The Lead CNA stated she did not have resident 293 on the schedule for a shower on potential for actual harm 1/20/25. The Lead CNA stated she did not have any other shower sheets which documented whether resident 293 had received or refused a shower, but would look through her stack of papers and provide them Residents Affected - Few if located. The Lead CNA stated the shower sheets were scanned by medical records into a file.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 30563

Residents Affected - Some Based on interview, observation and record review, the facility did not ensure that policies were established and implemented to ensure that identified quality deficiencies were corrected. Specifically, areas of immediate jeopardy (IJ) and harm were identified and not identified through the Quality Assurance and Performance Improvement (QAPI) process.

Findings include:

1. There was noncompliance identified at an IJ level for residents who were not assessed for smoking safety.

A resident was observed to have a burn hole in his pants.

2. There was noncompliance identified at a harm level for residents who experienced falls without updated interventions. Resident's sustained a injuries.

3. There was noncompliance identified at a harm level for a resident who was placed under an alarming call light system. The resident was also not allowed to go into his room.

4. There was noncompliance identified at a harm level for a resident who was not provided person centered care for mental disorders. Administration caused unnecessary psychological harm to a resident.

5. There was noncompliance identified at a harm level for a resident who did not receive treatment for a Urinary Tract Infection. In addition, the facility did not have a bowel and bladder retraining program.

On 2/6/25 at 3:25 PM, an interview was conducted with the Administrator (ADM). The ADM stated QAPI meetings were done monthly. The ADM stated that there was no December 2024 meeting because he had just started. The ADM stated the last QAPI was January 20 or 21st of 2025. The ADM stated trends were looked at for QAPI to determine what areas needed to be improved. The ADM stated he had not been at the facility long enough to determine trends. The ADM stated each department was in charge of presenting information. The ADM stated if there was a concern, then it was talked about and a power point presentation was developed. The ADM stated the QAPI team then determined what needed to happen before the next meeting. The ADM stated the Regional Nurse Consultant knew how to develop performance improvement plans (PIP) but he did not know how. The ADM stated smoking, bowel and bladder, and caring for residents with behavioral health were not discussed. The ADM stated cold food was discussed and grievances in the meeting. The ADM stated falls were discussed in the meeting as far as how many if if there were repeat falls.

The ADM stated he felt like there was a good plan in place for falls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50200 potential for actual harm Based on observation and interview it was determined, for 11 of 33 sampled residents, the facility did not Residents Affected - Some establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, enhanced barrier precautions (EBP) were not implemented for residents, the infection prevention and control program was not reviewed annually, there was no documentation for the testing of Legionella. Additionally, observations were made of a nurse was observed to handle resident's medications with bare hands and a staff member who did not perfor hand hygiene during meal service. Resident identifiers: 2, 3, 4, 5, 6, 9, 18, 25, 26, 31 and 32.

Findings included:

EBP

1. Resident 5 was admitted to the facility on [DATE REDACTED] with diagnoses which included, paraplegia, stage 4 pressure ulcers of the right and left buttocks, stage 4 pressure ulcer of sacral region, type 2 diabetes, and unspecified severe protein-calorie malnutrition.

On 1/27/25 at 9:28 AM, an observation was made of resident 5's room. There was no Personal Protective Equipment (PPE) inside or outside of the room and no EBP signage.

On 1/28/25 at 12:35 PM, an observation was made of resident 5's room. Resident 5 had a small cart with PPE located directly outside her room and an EBP sign was on the door.

A review of resident 5's care plan revealed that resident 5 had chronic wounds, a colostomy, suprapubic catheter, and PEG (percutaneous endoscopic gastrostomy) tube for enteral feeding.

On 2/4/25 at 10:16 AM, an interview was conducted with the Unit Manager/Infection Preventionist (UM/IP).

The UM stated EBP went into effect for the facility on 1/1/25. The UM stated EBP was used for any residents that had an indwelling device or wounds. The UM stated all residents who required EBP should have orders for EBP. The UM stated EBP was not implemented in the facility prior to last week.

On 2/4/25 at 12:46 PM, an interview was conducted with the Director of Nursing (DON). The DON stated EBP was started in the facility last week. The DON stated staff were educated about EBP last week in person and by phone. The DON stated it was the job of the infection preventionist to make sure EBP was done in the facility.

2. Resident 3 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses which included infection and inflammatory reaction due to other cardiac and vascular devices, Methicillin-resistant Staphylococcus aureus and end stage renal disease.

On 1/27/25, 1/28/25, 1/29/25, 1/30/25, 2/3/25 and 2/4/25, observations were made of resident 3's room. There was no signage or EBP outside or inside the room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0880 Resident 3's medical record was reviewed 1/27/25 though 2/6/25.

Level of Harm - Minimal harm or Resident 3 had a physician's order which revealed to monitor dialysis catheter every shift for potential potential for actual harm complications and signs and symptoms of infection.

Residents Affected - Some Another physician's order revealed to place a PICC (peripherally inserted central catheter) or midline one time for antibiotics on 12/28/24 and it was discontinued on 1/29/25.

There were no physician's order for EBP.

3. Resident 6 was admitted to the facility on [DATE REDACTED] with diagnoses which included type 2 diabetes mellitus with hyperglycemia, vascular wounds, muscle weakness, major depressive disorder and anxiety disorder.

On 1/27/25, 1/28/25, 1/29/25, 1/30/25 and 2/3/25 observations were made of resident 3's room. There was no signage or EBP inside or outside resident 3's room.

Resident 6's medical record was reviewed 1/27/25 through 2/6/25.

A physician's order dated 1/24/25 revealed there was a wound to the left lower leg.

A physician's order dated 2/4/25 revealed Isolation: enhanced barrier precautions (wounds to left lower leg).

On 1/29/25 at 9:25 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated she went into work on 1/28/25 and there were signs on resident room about EBP for residents with feeding tubes, catheters, and IV's (intravenous therapy). RN 2 stated she was not sure why resident 3 did not have EBP because she had a midline and a dialysis catheter. RN 2 stated CNA's were asking question on what EBP was because staff had not received training. RN 2 stated she was not sure what to do with the EBP because

she had not been provided training.

On 2/4/25 at 8:08 AM, an interview was conducted with CNA 4. CNA 4 stated there were signs outside the residents door if a resident needed isolation precautions. CNA 4 stated she was not caring for anyone with isolation precautions. CNA 4 stated she was not aware of EBP and did not know what she would need to wear. CNA 4 was taking care of the 300 hallway where resident 3 resided.

On 2/3/25 at 3:15 PM, an interview was conducted with the Lead CNA. The Lead CNA stated EBP was required by the state anytime staff were cleaning something that went into a residents body, like a site. The Lead CNA stated resident 5 did her own stuff so no one needed to wear gown or gloves. The Lead CNA stated resident 6 and resident 3 did not have EBP. The Lead CNA stated that resident 6 had wounds on his legs and resident 3 had a surgical wound.

On 2/4/25 at 12:48 PM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 3 needed EBP because of her dialysis catheter. The DON stated resident 6 needed to be on EBP because of his wounds.

On 2/6/25 at 9:19 AM, an interview was conducted with the UM. The UM stated the infection control and prevention program was not reviewed annually in 2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 91 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0880 A review of the facility Infection Prevention and Control policy on EBP adopted 5/1/24 documented:

Level of Harm - Minimal harm or POLICY: potential for actual harm

It is the policy of this facility to use Enhanced Barrier Precautions (EBP) to expand the use of PPE and to Residents Affected - Some refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multi-Drug Resistant Organisms (MDROs) to staff hands and clothing. MDROs may be indirectly transferred from resident to resident during these high-contact care activities.

Residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply for residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization .

Legionella Testing

On 2/5/25 at 9:09 AM, an interview was conducted with the Administrator (ADMIN). The ADMIN stated it was

the Director of Maintenance (DOM) who was in charge of water management for the facility.

On 2/5/25 at 12:20 PM, an interview was conducted with the DOM. The DOM stated he tested the water monthly for the presence of chlorine that would prevent Legionella in the water. The DOM stated he did not have any results, documentation, or logs recording the results of testing that was completed.

Medication Administration Observation

On 1/28/25 at 7:40 AM, an observation was made of Licensed Practical Nurse (LPN) 1 placing resident 3's medications directly into bare hands before transferring them into a medication cup.

On 1/28/25 at 7:55 AM, an observation was made of LPN 1. LPN 1 popped resident 4's divalproex out of blister pack into their bare hand before placing it into a medication cup. While preparing medications to be crushed, LPN 1 removed the divalproex from the medication cup with bare hand, opened capsules, and poured the contents into a Keppra solution medication cup.

On 1/28/25 at 8:15 AM, an observation was made of LPN 1. LPN 1 popped resident 26's carbamazepine out of blister pack into bare hand before placing it into a medication cup. The LPN then opened a bottle of acetaminophen, poured the tablets into bare hand, and placed them into the medication cup.

On 1/28/25 at 8:25 AM, an observation was made of LPN 1 popping resident 32's omeprazole out of blister pack into bare hand before placing it into a medication cup.

On 1/28/25 at 8:44 AM, an observation was made of LPN preparing medications for resident 9 when a gabapentin landed on top of the medication cart. The LPN picked medication up with a bare hand and placed

it into the medication cup.

30563

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0880 Dining Observation

Level of Harm - Minimal harm or On 1/27/25 at 11:59 AM, a dining observation was made of in the dining room. The Lead CNA was observed potential for actual harm to touch resident 18's utensils, then picked up cups, touched the beverage containers, filled up the cups, provided the cups to resident 25 and then touched the seat of a stool and wheeled the stool next to resident Residents Affected - Some 18, then touched resident 18's utensils, then cleaned resident 18's hands with wipes, touched the door handle to the kitchen, obtained a new spoon from the kitchen, touched a residents mug around the rim, fed resident 18 with the spoon, obtained a mug from the kitchen, picked up the beverage containers to fill the mug and gave the mug to a resident. The Lead CNA continued to touch resident's and their wheelchair handles, touched the door knob to the kitchen, touched the rim of a mug with coffee and gave it to resident 31. The Lead CNA was observed to touch resident 25, then the seat of the stool, her cell phone, resident 18's silverware, fed resident 18, touched a cabinet under the radio, touched the door handle to the kitchen, fed resident 18, picked up a cup, touched the beverage containers, filled the cup, gave the cup to another resident, touched the seat of the stool, picked up resident 4's drink by the rim, fed resident 4, touched resident 2's tray, put his napkin in his shirt, arranged his food closer to him and fed resident 18 without hand performing hygiene.

43212

47431

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 93 of 94 465163 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465163 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Monument Healthcare North Park 350 South 400 East 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 0949 Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Level of Harm - Minimal harm or 48709 potential for actual harm Based on interviews and record reviews it was determined the facility failed to provide behavioral health Residents Affected - Few training as determined by the facility assessment. Specifically, 4 staff members did not receive behavioral health training.

Findings include:

A review of the Facility Assessment Sandstone North Park, dated 5/20/24, indicated, a Resident Profile that reflected the facility's resident population included, Psychiatric /mood disorders [with common diagnoses of:] Psychosis (hallucinations, delusion, etc.), alterations in cognition, mental disorder, depression, manic depression, schizophrenia, post-traumatic stress disorder [PTSD], anxiety, behavioral expressions that need intervention. It further indicated, Services and Care We Offer Based on our Residents' Needs .Types of Care: Behavioral health. Specific Care or Practices: Behavioral support, behavioral healthcare needs such as dealing with anxiety, dementia care, memory care, care for depression, trauma/ PTSD, psychiatric diagnoses, intellectual or developmental disabilities. It further indicated, Direct care personnel complete a competency validation process in conjunction with new hire orientation and selected 'Core' competencies are completed annually. Competencies for our facility personnel include but are not limited to and or [Company name redacted] courses: Staff Competencies: Care of Residents with Psychosocial, Mental, and Behavioral Concerns. Including those with Substance Use Disorder, History of Trauma or PTSD. Emphasis on effective communication, meaningful activities, person-centered care approaches and non-pharmacological interventions.

A review of Licensed Practical Nurse (LPN) 1, Lead (Certified Nurse Assistant) CNA, CNA 6, and Unit Manager (UM) trainings did not include care of residents with psychosocial, mental, and behavioral concerns; history of trauma or PTSD; or person-centered care approaches and non-pharmacological interventions.

On 2/6/25 at 8:50 AM, an interview was conducted with the Administrator. The Administrator stated the facility had a lot of residents that have mental and behavioral health concerns and that staff should be trained

on how to handle that type of resident but that he was not sure if staff had been trained. A follow-up interview was conducted with the Administrator at 1:36 PM. The Administrator stated staff are trained for dementia but resident's with behavioral health needs like PTSD, depression or schizophrenia would not be handled the same as a resident with dementia.

On 2/6/25, an interview was conducted with the Director of Nursing. The DON stated the Facility Assessment was completed by the DON and the Administrator. The DON stated that there were no residents residing in

the facility that had any behavior concerns like aggressive behaviors or combativeness. The DON stated staff completed core training and that corporate decided what training they get. The DON stated training should be based on the Facility Assessment.

Cross refer to 742

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 94 of 94 465163