Inspection Reports for Monument Healthcare Murray Creek
3855 South 700 East, Salt Lake City, UT, 84106
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
62% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 1
Date: Jun 28, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of abuse involving residents and staff at Monument Healthcare Murray Creek.
Complaint Details
The complaint investigation substantiated abuse by a resident (Resident #346) who displayed sexually inappropriate behaviors affecting Residents #33, #71, and #351. Additionally, Registered Nurse (RN) #9 was found to have willfully yanked a walker from Resident #402 causing a fall and injury. RN #9's employment was terminated following the investigation.
Findings
The facility failed to protect residents from verbal, sexual, and physical abuse by a resident and a staff member. Four residents were affected by these deficient practices, including substantiated abuse by a registered nurse who was terminated.
Deficiencies (1)
Failure to protect residents from verbal, sexual, and physical abuse by a resident and staff.
Report Facts
Residents affected: 4
Sampled residents: 20
BIMS score: 15
BIMS score: 1
Fall date: Feb 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #9 | Registered Nurse | Named in physical abuse finding involving Resident #402 |
| Dietary Manager | Dietary Manager | Assigned to investigate grievance filed by Resident #351 |
| Director of Nursing | Director of Nursing | Received report of fall and abuse allegation involving Resident #402 and RN #9 |
| Maintenance Manager | Maintenance Manager | Reported incident and viewed video surveillance of fall involving Resident #402 |
| Former Administrator | Former Administrator | Involved in investigation and handling of abuse allegations |
Inspection Report
Routine
Deficiencies: 14
Date: Jun 28, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including medication administration, abuse prevention, care planning, activities of daily living, infection control, and resident rights.
Findings
The facility was found deficient in multiple areas including failure to assess residents for safe self-administration of medications, failure to protect residents from abuse by a resident and staff, failure to timely report and investigate abuse allegations, failure to develop comprehensive care plans for contractures, failure to provide personal hygiene care, failure to provide activities of choice and activity calendars, failure to document medication refusals and insulin administration, failure to provide proper binding arbitration agreements, failure to conduct quarterly QAPI meetings, failure to fit test staff annually, failure to follow infection control procedures during dialysis and respiratory care, and failure to ensure resident rooms met accessibility needs.
Deficiencies (14)
Failed to ensure Resident #58 was assessed to safely self-administer medication before nurse left medication at bedside.
Failed to protect residents from verbal, sexual, and physical abuse by resident and staff; substantiated abuse by RN #9 causing resident fall and injury.
Failed to timely report abuse allegations and submit investigation reports to state survey agency.
Failed to thoroughly investigate abuse allegations involving multiple residents.
Failed to develop and implement a care plan addressing left hand contracture for Resident #47.
Failed to provide personal hygiene care; Resident #399 had unshaved facial hair despite requests.
Failed to provide activity calendar and individualized activities for Resident #399.
Failed to provide treatment and services to increase range of motion for Resident #47's left hand contracture.
Failed to document medication refusal for Resident #97 and failed to document insulin administration and blood sugar for Resident #82.
Failed to ensure residents and/or representatives were afforded 30 days to revoke binding arbitration agreements.
Failed to ensure arbitration venue was convenient to both parties in binding arbitration agreements.
Failed to conduct quarterly Quality Assurance Performance Improvement (QAPI) meetings and maintain attendance records.
Failed to ensure staff were fit tested annually; failed to ensure proper hand hygiene during dialysis; failed to clean and store respiratory equipment properly.
Failed to ensure Resident #14's room provided enough space for motorized wheelchair access to bathroom.
Report Facts
Residents observed for medication administration: 5
Residents sampled for abuse review: 20
Residents reviewed for contracture care: 3
Residents reviewed for ADL care: 3
Residents reviewed for medication documentation: 5
Residents reviewed for insulin administration: 1
Residents reviewed for binding arbitration: 3
QAPI meetings documented: 2
Residents reviewed for infection control: 2
Residents reviewed for room accessibility: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #9 | Registered Nurse | Named in abuse incident causing resident fall and termination. |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding medication policies, abuse investigations, infection control, and care expectations. |
| Administrator | Administrator | Provided interviews regarding binding arbitration agreements, QAPI meetings, and overall facility expectations. |
| Marketing Admissions Director | Marketing Admissions Director | Responsible for obtaining binding arbitration agreements. |
| Occupational Therapist #18 | Occupational Therapist | Provided information on contracture treatment and monitoring. |
| Certified Nursing Assistant #21 | Certified Nursing Assistant | Provided care for Resident #47 and described contracture care. |
| Patient Care Technician #8 | Patient Care Technician | Observed failing to perform hand hygiene during dialysis care. |
| Registered Nurse #25 | Registered Nurse | Head nurse at dialysis center, confirmed hand hygiene expectations. |
| Registered Nurse Unit Manager #5 | Registered Nurse Unit Manager | Provided interviews on medication documentation and room accessibility. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jun 23, 2025
Visit Reason
The inspection was an unannounced annual inspection combined with a complaint investigation conducted from June 23 to June 28, 2025, to assess compliance with state nursing care facility regulations.
Complaint Details
The inspection included a complaint investigation component, but specific substantiation status or complaint details were not provided in the report.
Findings
The inspection identified five rule noncompliances related to various regulatory requirements including resident rights, care planning, medication management, and facility operations. The facility was found noncompliant in several areas such as resident rights protections, comprehensive care planning, and maintenance of medical records.
Deficiencies (5)
Failure to comply with resident rights including proper notification of transfer or discharge and ensuring privacy and dignity.
Incomplete or untimely development of comprehensive care plans for residents.
Failure to maintain accurate and complete medical records including documentation of assessments, care plans, and treatments.
Noncompliance with medication management policies including storage, administration, and monitoring of medications and restraints.
Inadequate emergency preparedness and maintenance of facility safety and sanitation standards.
Report Facts
Number of rule noncompliances: 5
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 31, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision and fall prevention interventions for a high-risk resident who sustained a maxillary fracture after a fall.
Complaint Details
The complaint investigation found that Resident 3, assessed as high fall risk, did not have a baseline care plan addressing falls prior to his fall on 9/11/23. The fall resulted in a maxillary fracture and hospitalization. The facility's fall prevention interventions were not in place before the incident.
Findings
The facility failed to ensure adequate supervision and fall prevention interventions for Resident 3, who was assessed as high risk for falls but did not have a baseline care plan addressing falls prior to the fall incident on 9/11/23. The resident sustained a maxillary fracture and was hospitalized. Interviews with staff confirmed the care plan for falls was initiated only after the fall.
Deficiencies (1)
Facility did not ensure that 1 out of 9 sampled residents received adequate supervision and assistance devices to prevent accidents, resulting in a fall and maxillary fracture.
Report Facts
Residents sampled: 9
Residents affected: 1
Fall risk evaluation date: Sep 1, 2023
Care plan initiation date: Sep 14, 2023
Fall incident date: Sep 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Interviewed regarding use of care plans and fall prevention interventions |
| Director of Nursing | Director of Nursing | Interviewed regarding fall prevention interventions and care plan procedures |
| MDS Coordinator | MDS Coordinator | Interviewed regarding care plan completion and fall risk assessments |
| CNA 1 | Certified Nursing Assistant | Interviewed regarding use of care plans and fall risk interventions |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 31, 2023
Visit Reason
The inspection was conducted due to an allegation of abuse involving two residents (Resident #11 and Resident #83) at Monument Healthcare Murray Creek.
Complaint Details
The complaint involved an allegation that Resident #83 struck Resident #11 on 08/03/2023. The investigation included interviews with the two residents and two CNAs but was inconclusive due to lack of comprehensive interviews and assessments. The facility did not monitor Resident #83 or complete a skin assessment on Resident #11 after the incident.
Findings
The facility failed to thoroughly investigate the abuse allegation, with incomplete interviews and assessments. The investigation was inconclusive, lacking documentation of interviews with all involved residents and no skin assessment was completed on the alleged victim despite the incident.
Deficiencies (1)
Failure to thoroughly investigate an allegation of abuse for two residents, including incomplete interviews and lack of documentation.
Report Facts
Residents reviewed for abuse prohibition: 5
Residents interviewed: 2
CNAs interviewed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #12 | Certified Nursing Assistant | Provided a written statement related to the abuse allegation |
| CNA #31 | Certified Nursing Assistant | Involved in the incident but no written statement provided |
| Administrator | Conducted interviews and provided investigation documentation | |
| Purchasing Director | Purchasing Director | Reviewed surveillance video and interviewed Resident #11 |
| Medical Director | Medical Director | Expected staff to interview residents and conduct assessments |
| Director of Nursing | Director of Nursing | Did not participate in investigation but expected nurse to complete skin assessment |
| Social Service Director | Social Service Director | Interviewed residents including Resident #44 and monitored Resident #11 for bruising |
Inspection Report
Routine
Deficiencies: 11
Date: Aug 31, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, safety, medication administration, respiratory care, resident assessments, care planning, activities of daily living, smoking safety, accident hazards, and dietary services.
Findings
The facility was found deficient in multiple areas including failure to properly assess residents for self-administration of medications and to have physician orders for medications left at bedside, incomplete and untimely resident assessments, inaccurate and incomplete care plans, inadequate assistance with activities of daily living such as grooming and hygiene, unsafe storage and handling of smoking materials, unsafe resident transfers and wheelchair transport, improper respiratory care including lack of physician orders for CPAP use and improper storage of respiratory equipment, and failure to consistently monitor food temperatures during meal service.
Deficiencies (11)
Failure to ensure residents self-administering medications were properly assessed and had physician orders for self-administration and medication storage at bedside.
Failure to submit a final investigative report within required five working days for an abuse allegation.
Failure to complete an admission Minimum Data Set (MDS) assessment timely for a resident.
Failure to complete quarterly MDS assessments timely for multiple residents.
Failure to ensure accurate coding of MDS assessments for cognitive status and fall with major injury.
Failure to develop comprehensive care plans addressing all resident needs including respiratory care, medication self-administration, dialysis, smoking, and medication monitoring.
Failure to provide adequate assistance with activities of daily living including grooming, shaving, nail care, and bathing for residents unable to perform these tasks.
Failure to safely store cigarettes and lighters, complete smoking assessments, and ensure safe resident transfers and wheelchair transport including use of gait belts and footrests.
Failure to provide appropriate respiratory care including obtaining physician orders for CPAP use and proper storage of respiratory equipment.
Failure to ensure procedures for receiving medications were accurate and safe, resulting in medication labeled as Methadone found in resident's backpack being placed in medication cart despite resident stating it was ibuprofen.
Failure to routinely monitor and document food temperatures on the meal service line, including failure to check milk temperatures on multiple days.
Report Facts
Residents affected by medication self-administration deficiency: 3
Residents affected by abuse report deficiency: 1
Residents affected by late admission MDS: 1
Residents affected by late quarterly MDS: 3
Residents affected by inaccurate MDS coding: 2
Residents affected by incomplete care plans: 8
Residents affected by inadequate ADL care: 3
Residents affected by unsafe smoking practices: 3
Residents affected by unsafe transfers or wheelchair transport: 2
Residents affected by respiratory care deficiencies: 4
Residents affected by medication receiving procedures: 1
Residents affected by food temperature monitoring deficiencies: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding medication self-administration and care plans |
| RN #2 | Registered Nurse | Interviewed regarding medication self-administration and care plans |
| DON | Director of Nursing | Interviewed regarding medication self-administration, care plans, respiratory care, smoking assessments, ADL care, and food temperature monitoring |
| Administrator | Interviewed regarding medication self-administration, care plans, respiratory care, smoking assessments, ADL care, medication receiving procedures, and food temperature monitoring | |
| RN #6 | Registered Nurse | Interviewed regarding respiratory equipment storage |
| RN #7 | Registered Nurse | Interviewed regarding care plans for antibiotics and insulin |
| RN #8 | Registered Nurse | Interviewed regarding smoking assessments and medication found in resident backpack |
| RN #17 | Registered Nurse | Observed transferring resident without gait belt |
| CNA #18 | Certified Nursing Assistant | Observed transferring resident without gait belt |
| PT #24 | Physical Therapist | Interviewed regarding safe transfer techniques and wheelchair footrests |
| RN #19 | Registered Nurse | Interviewed regarding nail care and smoking materials |
| CNA #3 | Certified Nursing Assistant | Interviewed regarding shower and grooming care |
| CNA #4 | Certified Nursing Assistant | Interviewed regarding shower and grooming care |
| CNA #5 | Certified Nursing Assistant | Interviewed regarding grooming care and razors availability |
| CNA #12 | Certified Nursing Assistant | Interviewed regarding shower and grooming care |
| Medical Director | Interviewed regarding expectations for care plans, respiratory care, grooming, and medication safety | |
| Regional Nurse Consultant | Interviewed regarding medication receiving procedures and smoking assessments | |
| Dietary Manager | Interviewed regarding food temperature monitoring | |
| Purchasing Director | Interviewed regarding razors availability |
Inspection Report
Routine
Deficiencies: 18
Date: Dec 6, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including resident care plans, pain management, infection control, staffing, food service, medication management, and safety. Specific issues included failure to provide reasonable accommodations, incomplete care plans, inadequate pain management, improper infection control practices, insufficient staffing, food quality concerns, medication storage issues, and failure to conduct required COVID-19 testing.
Deficiencies (18)
Resident was not given a bed with a frame that would allow elevation of legs and feet.
Facility did not ensure resident's advanced directives were honored due to lack of accessible POLST for nursing staff review.
Facility did not ensure residents had a safe, clean, comfortable and homelike environment; unclean shower room and loss of resident property.
Facility did not ensure prompt resolution of grievances for multiple residents.
Facility did not develop and implement comprehensive person-centered care plans for residents including communication, pressure ulcers, and pain management.
Facility did not provide appropriate treatment and services to maintain or improve residents' ability to perform activities of daily living.
Facility did not ensure residents unable to carry out activities of daily living received necessary services for nutrition, grooming, and hygiene.
Facility did not ensure residents received adequate supervision and assistive devices to prevent accidents; multiple falls and a resident hit by a meal cart.
Facility did not ensure residents received treatment and care in accordance with professional standards; therapy orders were not implemented.
Facility did not maintain acceptable parameters of nutritional status and did not offer therapeutic diet as ordered.
Facility did not provide safe, appropriate pain management consistent with professional standards and resident preferences.
Facility did not store drugs and biologicals under proper temperature; two medication refrigerators were out of safe range.
Facility did not ensure food was prepared, stored, and served in accordance with professional standards; unlabeled, expired, and moldy food found in communal refrigerators; dish machine sanitizer levels inadequate.
Facility did not ensure residents received drinks consistent with needs and preferences; a resident with thickened liquid order was given thin liquids.
Facility did not establish and maintain an infection prevention and control program; PPE not used properly, uncovered beverages transported, sputum on sidewalk, and delayed cleaning after COVID-19 cases.
Facility did not maintain medical records accurately; incomplete records for residents receiving dialysis and pain clinic services.
Facility did not ensure adequate nursing staff to meet resident needs; residents waited excessive times for care and infection control practices were compromised.
Facility did not conduct COVID-19 testing as required for unvaccinated staff during high community transmission and outbreak.
Report Facts
Sample residents: 49
Residents affected by deficiencies: 17
Medication refrigerator temperature: 32
Medication refrigerator temperature: 26
Sanitizer level: 10
Sanitizer level: 100
COVID-19 county positivity rate: 10.3
COVID-19 county positivity rate: 11.6
COVID-19 county positivity rate: 10.7
COVID-19 county positivity rate: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 4 | Registered Nurse | Interviewed regarding resident 18 fall risk and pain management |
| RN 5 | Registered Nurse | Interviewed regarding resident 97 wound care and infection |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding resident 22 medication and resident 70 therapy |
| CNA 4 | Certified Nursing Assistant | Observed delivering uncovered beverages and interviewed about resident 22 diet |
| CNA 6 | Certified Nursing Assistant | Observed delivering uncovered beverages and interviewed about resident 22 diet |
| Dietary Director | Interviewed regarding food service and dish machine sanitizer | |
| Housekeeping and Laundry Manager | Interviewed regarding laundry disinfectant and cleaning | |
| Executive Director | Interviewed regarding grievance resolution and infection control | |
| Infection Preventionist | Interviewed regarding infection control and medication administration |
Viewing
Loading inspection reports...
