Deficiencies (last 3 years)
Deficiencies (over 3 years)
24 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
204% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Routine
Deficiencies: 1
Date: Sep 4, 2025
Visit Reason
The inspection was conducted as a routine regulatory compliance check of the Monument American Fork nursing care facility to ensure adherence to state licensing rules and regulations.
Findings
The inspection checklist reviewed numerous regulatory requirements including policies, procedures, employee training, resident care, medication administration, and facility maintenance. The facility was found compliant in most areas, with one noted deficiency related to resident care services as indicated by a Level 3 deficiency (F676) for failure to provide necessary care and services to maintain or improve residents' abilities.
Deficiencies (1)
Failure to ensure each resident is provided necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, resulting in diminished abilities in activities of daily living.
Report Facts
Number of rule noncompliances: 1
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Sep 4, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to psychotropic medication use, residents' ability to perform activities of daily living, and infection prevention and control practices at Monument Healthcare American Fork.
Findings
The facility was found deficient in ensuring gradual dose reductions for psychotropic medications, providing appropriate assistance with eating to a legally blind resident, and maintaining an effective infection prevention and control program, specifically related to uncovered food items during meal delivery.
Deficiencies (3)
Failure to ensure residents using psychotropic drugs received gradual dose reductions (GDR) and behavioral interventions unless clinically contraindicated, specifically for 1 of 19 sampled residents.
Failure to ensure a resident received appropriate treatment and services to maintain or improve ability to perform activities of daily living, including eating, specifically a resident did not receive assistance with eating his meals.
Failure to establish and maintain an infection prevention and control program, with observations of staff carrying uncovered dessert and fruit cups down hallways during meal delivery.
Report Facts
Sampled residents: 19
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding psychotropic medication review and gradual dose reductions |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Observed and interviewed regarding assistance with feeding Resident 1 |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Interviewed regarding feeding assistance for Resident 1 |
| Registered Nurse | Registered Nurse | Interviewed regarding Resident 1's feeding assistance and condition |
| Dietary Manager | Dietary Manager | Interviewed regarding meal delivery practices and uncovered food items |
| Administrator | Administrator | Observed during meal tray service leaving cart doors open |
| Lead | Lead | Interviewed regarding feeding preferences and uncovered food items on meal trays |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 4, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to psychotropic medication use and residents' ability to perform activities of daily living.
Findings
The facility failed to ensure that residents using psychotropic drugs received gradual dose reductions unless clinically contraindicated, specifically for one resident. Additionally, the facility did not provide appropriate assistance with eating for a legally blind resident, resulting in a decline in the resident's ability to perform activities of daily living.
Deficiencies (2)
Failure to ensure residents using psychotropic drugs received gradual dose reductions (GDR) unless clinically contraindicated.
Failure to provide appropriate assistance with eating, resulting in loss of ability to perform activities of daily living.
Report Facts
Residents sampled: 19
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding psychotropic medication review and gradual dose reductions |
| CNA 1 | Certified Nursing Assistant | Observed and interviewed regarding assistance with feeding Resident 1 |
| CNA 2 | Certified Nursing Assistant | Interviewed regarding feeding assistance for Resident 1 |
| Dietary Manager | Dietary Manager | Interviewed regarding Resident 1's feeding needs |
| Registered Nurse | Registered Nurse | Interviewed regarding Resident 1's condition and assistance needs |
Inspection Report
Routine
Deficiencies: 1
Date: Sep 2, 2025
Visit Reason
Routine inspection conducted to ensure compliance with nursing care facility regulations and standards.
Findings
The inspection checklist reviewed multiple regulatory areas including resident care, staff qualifications, medication administration, emergency preparedness, and facility maintenance. One deficiency was cited related to resident care services not meeting the highest practicable physical, mental, and psychosocial well-being as per rule 150-14(1)(a-c).
Deficiencies (1)
Failure to ensure each resident is provided necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, as required by rule 150-14(1)(a-c).
Report Facts
Number of rule noncompliances: 1
Inspection Report
Annual Inspection
Deficiencies: 27
Date: Dec 6, 2023
Visit Reason
The inspection was conducted as an annual recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity and respect, inadequate care planning, medication errors, insufficient staffing, poor food quality and preparation, environmental hazards, delayed abuse reporting and investigation, and failure to provide adequate supervision to prevent accidents.
Deficiencies (27)
Failure to honor residents' rights to dignity, self-determination, and communication, including staff entering rooms without knocking and disrespectful staff behavior.
Failure to provide residents the right to participate in the development and implementation of person-centered care plans, including lack of family involvement.
Failure to ensure residents' right to self-administer medications was clinically evaluated and safe.
Failure to promote and facilitate resident self-determination and choice, including assistance with personal grooming services.
Failure to ensure residents' right to manage financial affairs, including lack of tracking resident funds and receipts.
Failure to provide residents notice of Medicaid/Medicare coverage and potential liability for services not covered, including failure to issue Notice of Medicare Non-coverage.
Failure to provide a safe, clean, comfortable, and homelike environment, including environmental disrepair, resident safety hazards, and lack of hot water.
Failure to protect residents from abuse, neglect, exploitation, and mistreatment, including failure to provide medication, nutrition, and fluids.
Failure to timely report suspected abuse, neglect, or theft and to report investigation results to proper authorities within required timeframes.
Failure to respond appropriately to all alleged violations, including incomplete investigations of neglect, injury, and elopement.
Failure to provide timely notification to residents, representatives, and ombudsman before transfer or discharge.
Failure to create and implement baseline care plans within 48 hours of admission for all residents.
Failure to develop and implement comprehensive care plans that meet all residents' needs, including monitoring of psychotropic medications, nutrition, and vision care.
Failure to provide care and assistance to perform activities of daily living including hygiene, grooming, oral care, and use of corrective lenses.
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, including failure to complete neurological checks after falls.
Failure to provide enough food and fluids to maintain residents' health, including failure to obtain current weights and implement timely nutritional interventions.
Failure to provide appropriate pharmaceutical services, including failure to provide routine and emergency drugs as ordered by the physician.
Failure to provide or obtain laboratory tests/services when ordered and promptly inform the ordering practitioner of the results.
Failure to implement an antibiotic stewardship program that monitors antibiotic use and ensures appropriate use of antibiotics.
Failure to ensure menus meet nutritional needs of residents, are prepared in advance, followed, updated, reviewed by dietitian, and meet resident needs.
Failure to ensure food is palatable, attractive, and served at safe and appetizing temperatures, including complaints of bland, cold, and poor quality food.
Failure to ensure food is prepared in a form designed to meet individual needs, including inappropriate preparation of pureed foods.
Failure to ensure meals and snacks are served at times in accordance with resident needs, preferences, and requests, including lack of nourishing snacks at bedtime or upon request.
Failure to procure food from approved sources and store, prepare, distribute and serve food in accordance with professional standards, including cross contamination and unsanitary conditions.
Failure to conduct and document a facility-wide assessment to determine necessary resources to care for residents competently during day-to-day operations and emergencies.
Failure to post nurse staffing information daily including facility name, date, number and hours worked by licensed and unlicensed nursing staff.
Failure to ensure nurse aides have the skills they need to care for residents, including education in dementia care and abuse prevention.
Report Facts
Deficiencies cited: 34
Residents sampled: 47
Facility census range: 65-75
Staff to resident ratio: 1:10 to 1:15
Weight loss percentage: 17.7
Weight loss percentage: 6.6
Water temperature: 131.9
Water temperature: 119.4
Medication doses: 3
Medication doses: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 10 | Certified Nursing Assistant | Observed and interviewed regarding staff behavior, shower refusals, and resident care |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding medication administration and resident care |
| DON | Director of Nursing | Interviewed regarding multiple care and administrative issues |
| ADM 1 | Administrator | Interviewed regarding abuse reporting and facility management |
| ADM 2 | Administrator | Interviewed regarding facility assessment and quality assurance |
| DM | Dietary Manager | Interviewed regarding food preparation, menus, and dietary services |
| RNC 1 | Regional Nurse Consultant | Interviewed regarding staffing and abuse investigations |
Inspection Report
Annual Inspection
Deficiencies: 25
Date: Dec 6, 2023
Visit Reason
The inspection was conducted as an annual recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity and respect, inadequate care planning and participation, failure to promote resident self-determination, improper management of resident finances, failure to provide a safe and clean environment, incidents of abuse and neglect, inadequate staffing, medication errors, poor nutritional care, food safety issues, and lack of effective quality assurance processes.
Deficiencies (25)
Failure to treat residents with dignity and respect, including staff entering rooms without knocking and staff yelling in hallways.
Failure to provide residents the right to participate in the development and implementation of a person-centered plan of care.
Failure to promote and facilitate resident self-determination through support of resident choice, including assistance with hair care.
Failure to ensure each resident had the right to manage his or her financial affairs, including lack of tracking of resident funds.
Failure to provide individual financial records through quarterly statements for residents with personal funds accounts.
Failure to inform residents periodically of services available and charges, including failure to issue Notice of Medicare Non-coverage.
Failure to provide a safe, clean, comfortable, and homelike environment, including disrepair, resident safety hazards, and lack of hot water.
Failure to protect residents from abuse, neglect, exploitation, and mistreatment, including failure to provide medication, nutrition, and fluids.
Failure to timely report suspected abuse, neglect, or theft and report the results of investigations to proper authorities.
Failure to respond appropriately to all alleged violations, including incomplete investigations of neglect, significant injury, and elopement.
Failure to provide timely notification to residents and representatives before transfer or discharge, including appeal rights.
Failure to create and implement a baseline care plan within 48 hours of admission for residents.
Failure to develop and implement a complete care plan that meets all resident needs, including monitoring psychotropic medication, nutrition, and vision care.
Failure to ensure residents do not lose the ability to perform activities of daily living unless medically necessary, including inadequate bathing and nail care.
Failure to provide care and assistance to perform activities of daily living, including oral care, use of corrective lenses, and wearing shoes.
Failure to provide appropriate treatment and care according to orders, resident preferences and goals, including medication errors and delayed care.
Failure to ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, including falls and loose handrails.
Failure to employ sufficient staff with appropriate competencies and skill sets to meet resident needs, including answering call lights timely and assisting with bathing.
Failure to provide pharmaceutical services to meet resident needs, including failure to provide routine and emergency drugs as ordered.
Failure to provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Failure to ensure menus meet nutritional needs of residents, are prepared in advance, followed, updated, reviewed by dietitian, and meet resident needs.
Failure to ensure meals and snacks are served at times in accordance with resident needs, preferences, and requests, including nourishing snacks at bedtime or upon request.
Failure to procure food from approved sources and store, prepare, distribute and serve food in accordance with professional standards, including cross contamination and unsanitary conditions.
Failure to conduct and document a facility-wide assessment to determine resources necessary to care for residents competently during day-to-day operations and emergencies.
Failure to ensure nurse aides have the skills they need to care for residents, including education in dementia care and abuse prevention.
Report Facts
Residents sampled: 47
Residents affected: 6
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 6
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 5
Residents affected: 5
Residents affected: 1
Residents affected: 4
Residents affected: 6
Residents affected: 6
Residents affected: 1
Residents affected: 2
Residents affected: 5
Residents affected: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 10 | Certified Nursing Assistant | Named in relation to staff behavior and care quality issues |
| CNA 1 | Certified Nursing Assistant | Named in relation to resident feeding and care observations |
| CNA 9 | Certified Nursing Assistant | Named in relation to resident feeding and care observations |
| LPN 3 | Licensed Practical Nurse | Named in relation to medication administration and care processes |
| LPN 2 | Licensed Practical Nurse | Named in relation to medication administration and care processes |
| LPN 4 | Licensed Practical Nurse | Named in relation to care planning and resident care |
| LPN 5 | Licensed Practical Nurse | Named in relation to resident care and safety |
| LPN 6 | Licensed Practical Nurse | Named in relation to resident fall and injury care |
| RN 1 | Registered Nurse | Named in relation to PICC line lab draw procedures |
| ADM 1 | Administrator | Named in relation to abuse reporting and investigation |
| ADM 2 | Administrator | Named in relation to abuse reporting and investigation |
| RNC 1 | Regional Nurse Consultant | Named in relation to abuse reporting and investigation |
| DM | Dietary Manager | Named in relation to food service and dietary management |
| RD | Registered Dietitian | Named in relation to food service and dietary management |
| CNA 4 | Certified Nursing Assistant | Named in relation to resident care and snack availability |
| CNA 6 | Certified Nursing Assistant | Named in relation to staffing and resident care |
Inspection Report
Routine
Deficiencies: 13
Date: Feb 28, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, abuse reporting, care planning, medication administration, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to provide written notice for room changes, delayed abuse reporting, inadequate care planning and implementation, missed dialysis treatments leading to resident death, medication administration issues, improper food storage, infection control lapses, broken resident equipment, and inadequate resident room size and amenities.
Deficiencies (13)
Failure to provide written notice to residents prior to room or roommate changes.
Failure to timely report suspected abuse, specifically a sexual abuse incident reported 4 days late.
Failure to develop and implement comprehensive person-centered care plans including interventions for incontinence, skin integrity, and nutrition.
Failure to provide necessary assistance with activities of daily living resulting in Moisture Associated Skin Damage (MASD).
Failure to ensure residents received treatment and care according to orders, including missed dialysis and critical lab values leading to death.
Failure to maintain adequate nutritional status and implement interventions for significant weight loss.
Failure to provide routine and emergency drugs as ordered due to pharmacy supply issues.
Failure to ensure drug regimens were free from unnecessary drugs, including failure to administer PRN antihypertensive medication when indicated.
Failure to store, prepare, distribute, and serve food in accordance with professional standards, including improper labeling and temperature control of resident communal refrigerators.
Failure to establish and maintain an infection prevention and control program, including staff not wearing proper eye protection and improper medication handling.
Failure to keep all essential equipment working safely, specifically a resident bed that was broken for at least two weeks without repair.
Failure to develop and implement appropriate Quality Assessment and Assurance (QAA) plans of correction for repeat deficiencies related to ADL care and immunizations.
Failure to ensure resident rooms met needs for adequate nursing care, comfort, and privacy, including storage of mobility aids in hallways and rooms smaller than required size with inadequate window access.
Report Facts
Residents sampled: 32
Deficiencies cited: 13
Resident weight loss percentage: 9.76
Potassium lab value: 6.9
Resident room size: 90
Resident room size minimum: 100
Resident snack refrigerator temperature: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Licensed Practical Nurse | Observed dropping medication capsule and not cleaning insulin pen before use |
| LPN 4 | Licensed Practical Nurse | Observed dropping medication capsule and not cleaning insulin pen before use |
| RN 1 | Registered Nurse | Agency nurse interviewed about Braden Scale and resident care |
| DON | Director of Nursing | Interviewed about dialysis scheduling, medication issues, QAA meetings, and immunizations |
| ADON | Assistant Director of Nursing | Interviewed about medication administration, dialysis scheduling, and immunizations |
| DM | Dietary Manager | Interviewed about food storage and kitchen responsibilities |
| Wound Nurse | Wound Nurse | Interviewed about resident 167's skin breakdown and bed functionality |
| CNA 4 | Certified Nursing Assistant | Interviewed about resident 167's care and catheter hygiene |
| CNA 3 | Certified Nursing Assistant | Interviewed about resident 167's care and incontinence checks |
| CNA 6 | Certified Nursing Assistant | Interviewed about refrigerator cleaning and maintenance requests |
| Maintenance Director | Maintenance Director | Interviewed about broken beds and maintenance work orders |
| Administrator | Facility Administrator | Interviewed about resident room size and immunization policies |
| MD | Medical Doctor | Interviewed about critical lab notification and dialysis care |
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