Deficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
28% better than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 3, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report alleged resident-to-resident abuse incidents to the State Survey Agency (SSA) and Adult Protective Services (APS).
Complaint Details
The complaint involved a resident-to-resident incident where Resident 36 punched Resident 20 in the back. The facility did not report the incident to the State Survey Agency or Adult Protective Services within the required timeframe. The Administrator chose not to report the incident, stating it was not abuse and no harm occurred, despite staff accounts and resident statements confirming the event.
Findings
The facility did not ensure that alleged abuse involving two residents was reported immediately, but not later than two hours after the allegation. Resident 36, with cognitive impairments, punched Resident 20 in the back, but the incident was not reported to the SSA. Interviews with staff and administration confirmed the failure to report and investigate the incident as required.
Deficiencies (1)
Failure to timely report suspected abuse involving resident-to-resident altercation to proper authorities.
Report Facts
Residents sampled: 27
Residents affected: 2
Incident date: Feb 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Reported the incident to the Director of Nursing and notified the Administrator; involved in managing the incident |
| Director of Nursing | Director of Nursing | Received report of the incident from LPN 1 and consulted with administration |
| ADMIN | Administrator | Facility Administrator and abuse coordinator who chose not to report the incident to SSA |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed regarding the incident and expressed preference that the Administrator had reported the incident |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Apr 3, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged resident-to-resident abuse and failure to report and investigate the incident properly.
Complaint Details
The complaint involved allegations of resident-to-resident abuse where a cognitively impaired resident punched another resident. The facility failed to report the incident timely and did not investigate the allegations thoroughly. The abuse was determined to be not willful by the administrator, who chose not to report it to the State Survey Agency.
Findings
The facility failed to timely report suspected abuse involving two residents and did not thoroughly investigate the alleged abuse. Additionally, deficiencies were found in care planning, supervision to prevent accidents, medication administration, infection prevention, antibiotic stewardship, psychotropic medication management, and food safety.
Deficiencies (8)
Failure to timely report suspected abuse to the State Survey Agency and Adult Protective Services for two residents involved in a resident-to-resident altercation.
Failure to thoroughly investigate alleged abuse involving two residents.
Failure to develop and implement a baseline care plan within 48 hours of admission for a resident at high risk for falls.
Failure to maintain a safe environment and provide adequate supervision to prevent accidents, including medication left at bedside and lack of fall interventions.
Failure to provide appropriate care to prevent urinary tract infections, including administering an ineffective antibiotic and delayed appropriate treatment.
Failure to implement gradual dose reductions for psychotropic medications unless clinically contraindicated.
Failure to store, prepare, distribute, and serve food in accordance with professional standards, including expired and unlabeled food and a dish machine not sanitizing properly.
Failure to establish an antibiotic stewardship program that includes protocols and monitoring of antibiotic use.
Report Facts
Residents sampled: 27
Residents affected: 2
Morse Fall Scale score: 50
BIMS score: 99
BIMS score: 14
Medication dosage: 2
Medication dosage: 10
Sanitizer level: 100
Antibiotic dosage: 500
Antibiotic dosage: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to failure to report abuse and medication administration issues | |
| Administrator | Abuse coordinator who chose not to report the resident-to-resident abuse incident | |
| Licensed Practical Nurse 1 | Witnessed and reported the resident-to-resident abuse incident | |
| Regional Nurse Consultant | Interviewed regarding abuse reporting and investigation | |
| Registered Nurse 1 | Interviewed regarding medication administration and UTI care | |
| Dietary Manager | Responsible for kitchen operations and food safety | |
| Infection Preventionist | Interviewed regarding antibiotic stewardship and UTI management |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 31, 2025
Visit Reason
The inspection was an unannounced routine inspection conducted to ensure compliance with nursing care facility regulations.
Findings
The inspection checklist reviewed multiple regulatory requirements including policies, procedures, employee rosters, grievance logs, and fall policies. Four rule noncompliances were identified during the inspection.
Deficiencies (1)
The licensee did not comply with the requirement that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization is necessary.
Report Facts
Number of rule noncompliances: 4
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Aug 24, 2023
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident abuse, including failure to provide requested medical records and failure to protect residents from sexual abuse by another resident.
Complaint Details
The complaint investigation involved allegations that the facility failed to provide requested medical records to Resident #37, failed to protect Resident #4 from sexual abuse by Resident #189 on two occasions, failed to develop and implement appropriate care plans to prevent abuse, and failed to timely report abuse allegations involving multiple residents to the state survey agency.
Findings
The facility failed to protect a resident's right to obtain copies of medical records, failed to protect a resident from sexual abuse by another resident, failed to develop and implement appropriate care plans to prevent resident-to-resident sexual abuse, and failed to timely report allegations of abuse to the state survey agency within required timeframes.
Deficiencies (4)
Failed to protect Resident #37's right to obtain copies of medical records upon request.
Failed to protect Resident #4 from sexual abuse by Resident #189, including incidents on 10/23/2022 and 12/26/2022.
Failed to develop and implement a care plan with appropriate interventions to prevent resident-to-resident sexual abuse by Resident #189.
Failed to timely report allegations of abuse involving Residents #4, #189, #15, #19, and #16 within the required two-hour timeframe.
Report Facts
Dates of sexually inappropriate behavior: 57
Dates of incidents: 2
Dates of report delay: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #12 | Certified Nursing Assistant | Responsible for medical records and medical record requests; involved in the failure to provide Resident #37's full medical records. |
| Director of Nursing | Director of Nursing | Interviewed regarding medical records process and resident-to-resident abuse expectations. |
| Administrator | Administrator | Interviewed regarding medical records process, abuse reporting, and facility policies. |
| RN #9 | Registered Nurse | Reported Resident #189's sexual behaviors and involvement in abuse incidents. |
| LPN #11 | Licensed Practical Nurse | Reported witnessing and documenting sexual abuse incident on 10/23/2022. |
| CNA #21 | Certified Nursing Assistant | Reported staff supervision interventions for Resident #189. |
| NP #4 | Nurse Practitioner | Evaluated Resident #15 and Resident #19 regarding abuse allegations. |
| CNA #19 | Certified Nursing Assistant | Reported Resident #19's allegation of inappropriate touching by Resident #16. |
| LPN #22 | Licensed Practical Nurse | Received Resident #19's allegation and notified DON and Administrator. |
| Cook #10 | Kitchen Staff | Witnessed and intervened in sexual abuse incident on 12/26/2022. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 24, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Monument Healthcare Pioneer Trail.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 14, 2021
Visit Reason
The inspection was conducted following complaints regarding missing personal belongings of a resident, inadequate catheter care leading to urinary tract infection, and failure to conduct required COVID-19 testing on staff.
Complaint Details
The complaint investigation involved a resident missing a personal blanket for over a month without resolution, a resident with catheter-related urinary tract infection signs not receiving appropriate treatment, and a staff member not tested twice weekly for COVID-19 as required during high community transmission.
Findings
The facility failed to provide a safe, clean, and homelike environment by not locating or replacing a resident's missing personal blanket. Additionally, the facility did not ensure appropriate catheter care for a resident with a urinary tract infection, resulting in untreated infection signs. The facility also failed to conduct required twice-weekly COVID-19 testing for an unvaccinated staff member during high community transmission periods.
Deficiencies (3)
Failure to honor the resident's right to a safe, clean, comfortable and homelike environment, including not locating or replacing a missing personal blanket.
Failure to provide appropriate catheter care and treatment to prevent urinary tract infections for a resident with an indwelling catheter.
Failure to perform required COVID-19 testing on staff according to community transmission rates, with one staff member missing multiple tests.
Report Facts
Residents affected: 1
Residents affected: 1
Staff affected: 1
Dates of missed COVID-19 testing: 3
Urine culture colony forming units: 100000
Catheter size: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Interviewed regarding missing blanket and catheter care |
| Housekeeping Manager | Housekeeping Manager | Interviewed regarding search for missing blanket |
| CNA 3 | Certified Nursing Assistant | Interviewed regarding search for missing blanket and reporting to Director of Nursing |
| DON | Director of Nursing | Interviewed regarding catheter care and missing blanket process |
| Social Worker | Social Worker | Interviewed regarding grievance process for missing items |
| IP | Infection Preventionist | Interviewed regarding COVID-19 testing deficiencies |
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