Inspection Report — Sep 4, 2025
Annual Inspection
Deficiencies: 2
Date: Sep 4, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulations regarding 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, and failed to provide appropriate assistance with eating for a legally blind resident with activities of daily living deficits.
Deficiencies (2)
F 0605: The facility did not ensure that residents using psychotropic drugs received gradual dose reductions or behavioral interventions unless clinically contraindicated. Resident 20 had no documented attempted gradual dose reduction for clozapine since March 2023.
F 0676: The facility did not ensure that a resident received appropriate assistance with eating to maintain or improve activities of daily living. Resident 1, who was legally blind and had hemiplegia, did not consistently receive needed assistance with meals.
Report Facts
Sampled residents: 19
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding psychotropic medication review meetings and gradual dose reductions | |
| Lead [NAME] | Interviewed about Resident 1's feeding preferences and abilities | |
| Dietary Manager | Interviewed about Resident 1's eating assistance | |
| Certified Nursing Assistant (CNA) 1 | Interviewed about assisting Resident 1 with eating | |
| Certified Nursing Assistant (CNA) 2 | Interviewed about feeding assistance for Resident 1 | |
| Registered Nurse (RN) | Interviewed about Resident 1's condition and assistance needs |
Inspection Report — Sep 4, 2025
Routine
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 failed to ensure gradual dose reductions for psychotropic medications for one resident, did not provide appropriate assistance with eating for one resident, and did not maintain an effective infection prevention and control program, as evidenced by uncovered food items being served in hallways.
Deficiencies (3)
F 0605: The facility did not ensure residents using psychotropic drugs received gradual dose reductions or behavioral interventions unless clinically contraindicated. Resident 20 had no documented gradual dose reduction for clozapine since March 2023.
F 0676: The facility did not ensure a resident received appropriate assistance with eating meals. Resident 1, who was legally blind and had hemiplegia, was observed without needed feeding assistance.
F 0880: The facility failed to establish and maintain an infection prevention and control program. Staff were observed carrying uncovered desserts and fruit cups down hallways during meal service.
Report Facts
Sampled residents: 19
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding psychotropic medication review and gradual dose reductions | |
| Lead [NAME] | Interviewed about Resident 1's feeding needs and infection control practices | |
| Dietary Manager | Interviewed about feeding assistance and infection control practices | |
| Certified Nursing Assistant (CNA) 1 | Interviewed about feeding assistance provided to Resident 1 | |
| Certified Nursing Assistant (CNA) 2 | Interviewed about feeding assistance for Resident 1 | |
| Registered Nurse (RN) | Interviewed about Resident 1's feeding assistance needs | |
| Administrator | Observed during meal service related to infection control |
Inspection Report — Sep 2, 2025
Routine
Deficiencies: 1
Date: Sep 2, 2025
Visit Reason
Routine inspection checklist conducted to ensure compliance with Utah Department of Health & Human Services nursing care facility regulations.
Findings
The inspection checklist documents compliance and noncompliance with various nursing care facility rules, including resident rights, care plans, medication administration, staffing, and facility maintenance. Several rules were marked as noncompliant, indicating areas needing correction.
Deficiencies (1)
R432-150-14(1)(a-c) The licensee failed to ensure each resident is provided necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being as per the comprehensive assessment and care plan.
Report Facts
Number of rule noncompliances: 32
Inspection Report — Dec 6, 2023
Annual Inspection
Deficiencies: 32
Date: Dec 6, 2023
Visit Reason
Annual recertification survey and complaint investigation of Monument Healthcare American Fork to assess compliance with state and federal regulations.
Complaint Details
Complaint investigations revealed multiple deficiencies including abuse reporting delays, medication errors, inadequate care planning, and failure to provide adequate nutrition and hydration.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, care planning, self-determination, financial management, Medicaid/Medicare notices, environment safety and cleanliness, abuse reporting and investigation, medication administration, nutrition and hydration, staffing adequacy, food service quality, and infection control.
Deficiencies (32)
F550: Facility failed to treat residents with dignity and respect, including staff entering rooms without knocking and staff verbal altercations in resident areas.
F553: Facility failed to allow resident participation in person-centered care planning and failed to include family representatives in care conferences.
F561: Facility failed to promote and facilitate resident self-determination, including assistance with personal grooming requests.
F567: Facility failed to ensure residents' right to manage financial affairs, including lack of tracking and documentation of resident funds.
F568: Facility failed to provide individual financial statements quarterly to residents with personal funds accounts.
F582: Facility failed to provide Notice of Medicare Non-Coverage to residents discharged from Medicare Part A services.
F584: Facility environment was unsafe and unclean, including broken fixtures, peeling paint, missing hot water, and soiled resident rooms.
F600: Facility failed to protect residents from abuse, neglect, and exploitation, including failure to provide medication, nutrition, and fluids to a resident.
F609: Facility failed to report allegations of abuse, neglect, or exploitation to the State Survey Agency within required timeframes and failed to conduct thorough investigations.
F610: Facility failed to respond appropriately to allegations of abuse, neglect, or exploitation, including incomplete investigations and delayed reporting.
F623: Facility failed to provide timely notification of resident discharges and hospitalizations to the Long-Term Care Ombudsman.
F655: Facility failed to develop and implement a baseline care plan within 48 hours of admission for a respite resident.
F656: Facility failed to develop and implement comprehensive care plans that addressed all resident needs including nutrition, medication monitoring, and vision care.
F676: Facility failed to provide adequate supervision and accident prevention, resulting in resident falls with injuries and inadequate post-fall assessments.
F677: Facility failed to provide care and assistance with activities of daily living including bathing, grooming, oral care, and assistance with eating.
F684: Facility environment was unsafe with loose handrails and other hazards posing risk to residents.
F692: Facility failed to maintain acceptable nutritional status for residents, including failure to obtain current weights and provide appropriate supplements and assistance.
F725: Facility failed to provide sufficient nursing staff to meet resident needs including timely response to call lights, assistance with bathing, and obtaining weights.
F732: Facility failed to post daily nurse staffing information as required.
F755: Facility failed to employ a full-time qualified dietitian or clinically qualified nutrition professional as director of food and nutrition services.
F804: Facility failed to ensure menus were followed and residents received appropriate fortified diets.
F805: Facility failed to provide food that was palatable, attractive, and at safe temperatures; pureed foods were watery and bland.
F809: Facility failed to provide meals that accommodated resident allergies, intolerances, and preferences.
F812: Facility failed to provide nourishing snacks at bedtime or upon request.
F838: Facility failed to store, prepare, distribute and serve food in accordance with professional standards, including cross contamination and unclean kitchen conditions.
F867: Facility failed to conduct and document a comprehensive facility assessment addressing resident needs, staffing, environment, and other factors.
F880: Facility failed to ensure residents received treatment and care in accordance with professional standards, including medication administration errors and failure to monitor post-fall neuro checks.
F881: Facility failed to ensure residents were free from significant medication errors, including failure to administer medications as ordered and medication discrepancies.
F892: Facility failed to obtain laboratory tests only when ordered by a physician and failed to notify providers of results timely.
F908: Facility failed to provide sufficient staffing to meet resident needs and acuity, including inadequate nurse and CNA staffing ratios.
F924: Facility failed to ensure corridors were equipped with firmly secured handrails to prevent resident accidents.
F947: Facility failed to provide sufficient nurse aide training including dementia care and abuse prevention.
Report Facts
Sampled residents: 47
Repeat deficiencies: 12
Weight loss: 32
Weight loss percent: 17
Shower frequency: 3
Hot water temperature: 131.9
Milk temperature: 52.5
Sample tray observation time: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 10 | Certified Nursing Assistant | Named in findings regarding staff behavior and shower refusals |
| LPN 3 | Licensed Practical Nurse | Named in medication administration and admission order findings |
| DON | Director of Nursing | Named in multiple interviews regarding facility operations and deficiencies |
| DM | Dietary Manager | Named in interviews regarding food service and menu deficiencies |
| RD | Registered Dietitian | Named in interviews regarding nutrition and menu planning |
| ADM 1 | Administrator | Named in interviews regarding facility management and quality assurance |
| ADM 2 | Administrator | Named in interviews regarding facility management and quality assurance |
| RNC 1 | Regional Nurse Consultant | Named in interviews regarding survey and facility oversight |
Inspection Report — Feb 28, 2022
Routine
Deficiencies: 16
Date: Feb 28, 2022
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, medication management, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to provide written notice for room changes, delayed reporting of abuse allegations, incomplete care plans, missed dialysis treatments resulting in resident death, inadequate nutritional interventions for significant weight loss, medication administration issues, infection control lapses, maintenance of resident equipment, and inadequate resident room size and amenities.
Deficiencies (16)
F559: The facility did not provide written notice before changing a resident's room or roommate for 2 of 32 sampled residents.
F609: The facility failed to timely report an incident of employee to resident sexual abuse to the State Survey Agency and Adult Protective Services within 2 hours.
F656: The facility did not develop and implement comprehensive person-centered care plans with measurable objectives for 2 of 32 sampled residents, including interventions for incontinence, skin integrity, and nutrition.
F661: The facility did not ensure a resident's discharge summary was complete, lacking recapitulation of stay, final status, medication reconciliation, and post-discharge plan for 1 of 32 sampled residents.
F677: The facility did not provide necessary care and assistance for activities of daily living, resulting in Moisture Associated Skin Damage for 1 of 32 sampled residents.
F684: The facility failed to provide treatment and care according to orders and resident preferences, resulting in a missed dialysis day and two critical potassium lab values with no intervention, leading to resident death.
F755: The facility did not provide routine and emergency drugs as ordered due to medication unavailability by the pharmacy for 3 of 32 sampled residents.
F757: The facility did not ensure each resident's drug regimen was free from unnecessary drugs; hypertensive medication was not administered when blood pressure exceeded physician parameters for 1 of 32 sampled residents.
F812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards; communal refrigerators contained unlabeled items and were maintained at improper temperatures.
F867: The facility did not ensure the Quality Assessment and Assurance committee developed and implemented appropriate corrective plans for repeat deficiencies including ADL care and immunization documentation.
F880: Staff provided direct resident care on the COVID-19 unit without proper eye protection and failed to follow infection control practices including hand hygiene and medication handling.
F908: The facility did not ensure all mechanical and patient care equipment were kept in safe operating condition; a resident had a broken bed for at least two weeks without repair.
F910: The facility did not ensure resident rooms were designed and equipped for adequate nursing care, comfort, and privacy; a resident's walker and wheelchair were stored in the hallway and the room was small.
F912: The facility did not ensure a single resident room measured at least 100 square feet; the resident's usable living space measured approximately 90 square feet.
F915: The facility did not ensure a resident bedroom had a window to the outside; the window was located in the bathroom and not visible from the resident's bed.
F883: The facility did not document education or consent regarding influenza and pneumococcal immunizations for 1 of 32 sampled residents; immunizations were not administered or refused.
Report Facts
Residents sampled: 32
Potassium lab value: 8.7
Resident 51 weight loss percentage: 9.76
Resident 51 weight loss percentage: 9.66
Resident 51 weight: 243.5
Resident 51 weight: 209.4
Resident 113 room size: 90
Resident communal snack refrigerator temperature: 46
Resident 22 blood pressure: 188
Resident 22 blood pressure: 171
Resident 22 blood pressure: 172
Resident 22 blood pressure: 166
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed about room changes, abuse reporting, care plans, medication issues, immunizations, and QAA meetings | |
| Assistant Director of Nursing | Interviewed about care plans, medication scheduling, immunizations, infection control, and QAA meetings | |
| Licensed Practical Nurse (LPN) 3 | Interviewed about medication administration and resident care | |
| Licensed Practical Nurse (LPN) 4 | Observed and interviewed regarding medication administration and infection control | |
| Certified Nursing Assistant (CNA) 3 | Observed providing care without eye protection | |
| Certified Nursing Assistant (CNA) 1 | Observed providing care without eye protection | |
| Wound Nurse | Interviewed about resident bed and skin care | |
| Maintenance Director | Interviewed about bed repairs and maintenance requests | |
| Dietary Manager | Interviewed about food storage and kitchen responsibilities | |
| Registered Dietician | Interviewed about nutritional interventions for resident 51 | |
| Administrator | Interviewed about room size, immunizations, and QAA meetings | |
| Medical Doctor | Interviewed about critical lab notifications and resident 111 care |
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