Deficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% better than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
12
9
6
3
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 suspected resident-to-resident abuse involving a resident with cognitive impairments who punched another resident.
Complaint Details
The complaint investigation was substantiated. The facility did not report a resident-to-resident abuse incident involving resident 36 punching resident 20. The Administrator and Director of Nursing chose not to report the incident to the State Survey Agency, citing that resident 36 did not act willfully. The Regional Nurse Consultant disagreed with this decision and preferred the incident be reported.
Findings
The facility did not ensure that all alleged abuse violations were reported immediately, within two hours, to the State Survey Agency and Adult Protective Services. The incident involved resident 36 punching resident 20 in the back, but the facility chose not to report the incident, considering it not willful abuse.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to proper authorities within two hours as required. Specifically, notification to the State Survey Agency and Adult Protective Services was not made for an incident where resident 36 punched resident 20.
Report Facts
Residents sampled: 27
Date of survey completion: Apr 3, 2025
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Apr 3, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to timely report and investigate alleged resident-to-resident abuse incidents and other care concerns.
Complaint Details
The complaint investigation focused on failure to timely report and investigate alleged resident-to-resident abuse involving residents 20 and 36. The facility did not report the incident to the State Survey Agency within two hours and did not thoroughly investigate the abuse allegations. The Administrator chose not to report the incident, believing it was not abuse. The Regional Nurse Consultant disagreed with this decision.
Findings
The facility failed to timely report alleged abuse incidents to the State Survey Agency and Adult Protective Services, did not thoroughly investigate abuse allegations, failed to develop baseline care plans within 48 hours for a high fall risk resident, did not ensure safe medication administration, failed to prevent accidents, and did not provide appropriate care to prevent urinary tract infections. Additionally, the facility did not implement gradual dose reductions for psychotropic medications, did not maintain food safety standards, and lacked an effective antibiotic stewardship program.
Deficiencies (8)
F 0609: The facility did not ensure timely reporting of suspected abuse to proper authorities within two hours for 2 of 27 residents involved in a resident-to-resident altercation.
F 0610: The facility failed to thoroughly investigate all alleged abuse violations for 2 of 27 residents involved in a resident-to-resident abuse allegation.
F 0655: The facility did not develop and implement a baseline care plan within 48 hours of admission for a resident at high risk for falls.
F 0689: The facility did not maintain a safe environment and adequate supervision to prevent accidents for 2 of 27 residents, including medication left at bedside and lack of fall interventions.
F 0690: The facility failed to provide appropriate care to prevent urinary tract infections for 1 of 27 residents by administering an ineffective antibiotic and delayed appropriate treatment.
F 0758: The facility did not implement gradual dose reductions for psychotropic medications for 1 of 27 residents receiving an antidepressant since April 2024.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards, including expired and unlabeled food and a dish machine not sanitizing properly.
F 0881: The facility failed to establish an antibiotic stewardship program that included monitoring antibiotic use, resulting in a resident receiving an ineffective antibiotic for a urinary tract infection.
Report Facts
Residents sampled: 27
BIMS score: 99
Fall risk score: 50
Medication dosage: 500
Sanitizer level: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to abuse reporting and medication administration findings | |
| Administrator | Named in relation to abuse reporting and investigation decisions | |
| Licensed Practical Nurse (LPN) 1 | Witnessed abuse incident and reported to DON and Administrator | |
| Registered Nurse (RN) 1 | Interviewed regarding medication administration and resident condition | |
| Regional Nurse Consultant | Interviewed regarding abuse reporting and investigation | |
| Dietary Manager | Interviewed regarding food safety and dish machine sanitization | |
| Infection Preventionist | Interviewed regarding antibiotic stewardship and UTI treatment |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 31, 2025
Visit Reason
The inspection was an unannounced routine visit to review compliance with nursing care facility regulations.
Findings
The facility was found to be compliant with most nursing care facility regulations, with a few areas noted as not compliant. The inspection covered a wide range of regulatory requirements including resident rights, care plans, medication management, staffing, and facility maintenance.
Deficiencies (3)
R432-150-4(4)(a-b) The licensee did not ensure a resident who enters the facility without an indwelling catheter is not catheterized unless clinically necessary.
R432-150-14(4)(a-b) The licensee did not ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections.
R432-150-14(4)(a-b) The licensee did not ensure a resident who is incontinent of bowel or bladder receives treatment and services to restore as much normal functioning as possible.
Report Facts
Number of rule noncompliances: 4
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 24, 2023
Visit Reason
The inspection was conducted due to complaints and allegations of failure to protect residents' rights, including failure to provide medical records upon request and failure to protect residents from sexual abuse by another resident.
Complaint Details
The complaint investigation involved failure to provide medical records to Resident #37 and failure to protect Resident #4 from sexual abuse by Resident #189. Multiple allegations of abuse involving Residents #4, #189, #15, #19, and #16 were not reported timely to the state survey agency. The facility's response and care planning were inadequate to prevent further abuse.
Findings
The facility failed to protect Resident #37's right to obtain copies of medical records. The facility also failed to protect Resident #4 from sexual abuse by Resident #189, who exhibited ongoing sexually inappropriate behaviors despite interventions. Additionally, the facility failed to timely report multiple allegations of abuse to the state survey agency and did not fully implement care plan interventions to prevent resident-to-resident sexual abuse.
Deficiencies (5)
F 0573: The facility failed to provide Resident #37 access to all requested medical records in a timely manner, resulting in incomplete release of records and destruction of unclaimed records.
F 0600: The facility failed to protect Resident #4 from sexual abuse by Resident #189, who touched Resident #4 inappropriately multiple times despite known behaviors and care plan interventions.
F 0607: The facility failed to develop and implement policies and procedures to prevent abuse by not protecting Resident #4 from further sexual abuse by Resident #189 after the initial incident.
F 0609: The facility failed to timely report allegations of abuse involving Residents #4, #189, #15, #19, and #16 to the state survey agency within required timeframes.
F 0656: The facility failed to develop and implement a complete care plan with effective interventions to prevent resident-to-resident sexual abuse by Resident #189, who continued inappropriate sexual behaviors despite redirection efforts.
Report Facts
Dates sexually inappropriate behavior recorded: 57
Residents affected by abuse allegations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #11 | Licensed Practical Nurse | Reported and documented Resident #189's inappropriate touching of Resident #4 on 10/23/2022 |
| RN #9 | Registered Nurse | Reported Resident #189's sexual behaviors and involvement in abuse incidents |
| CNA #12 | Certified Nursing Assistant | Responsible for medical records and record requests related to Resident #37 |
| DON | Director of Nursing | Provided expectations on abuse reporting and care plan implementation |
| Administrator | Facility Administrator | Provided information on abuse reporting policies and facility procedures |
| CNA #21 | Certified Nursing Assistant | Reported staff instructions to monitor Resident #189 for sexual inappropriate behavior |
| RN #2 | Registered Nurse | Described Resident #189's mental illness and sexual behaviors |
| NP #4 | Nurse Practitioner | Evaluated Resident #15 and Resident #19 and documented abuse allegations |
| CNA #19 | Certified Nursing Assistant | Received abuse allegation from Resident #19 and reported to LPN #22 |
| LPN #22 | Licensed Practical Nurse | Received abuse allegation from Resident #19 and notified DON and Administrator |
| Cook #10 | Kitchen Staff | Witnessed and intervened during Resident #189's abuse of Resident #4 on 12/26/2022 |
Inspection Report
Deficiencies: 0
Date: Aug 24, 2023
Visit Reason
The inspection was conducted as a regulatory survey to assess compliance with health and safety standards 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 to investigate complaints regarding missing personal belongings of a resident, inadequate catheter care leading to urinary tract infections, and failure to conduct required COVID-19 testing on staff.
Complaint Details
The investigation was complaint-driven, focusing on missing resident belongings, inadequate catheter care leading to urinary tract infection, and failure to conduct required COVID-19 testing on staff. The findings confirmed deficiencies in all three areas.
Findings
The facility failed to provide a safe and homelike environment by not locating or replacing a resident's missing personal blanket. The facility did not ensure appropriate catheter care for a resident with a urinary tract infection, resulting in untreated infection signs. Additionally, the facility did not conduct required twice-weekly COVID-19 testing for a staff member during periods of high community transmission.
Deficiencies (3)
F 0584: The facility did not provide a safe, clean, and homelike environment, failing to locate or replace a resident's missing personal blanket despite staff searches and family notification.
F 0690: The facility did not ensure appropriate catheter care for a resident with a urinary tract infection, resulting in untreated infection signs despite positive urine culture and symptoms.
F 0886: The facility failed to conduct required twice-weekly COVID-19 testing for a staff member during periods of high community transmission as mandated by CDC and CMS guidelines.
Report Facts
Residents affected: 1
Residents affected: 1
Staff sample size: 5
Missed staff tests: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Interviewed regarding missing resident blanket and catheter care |
| HM | Housekeeping Manager | Interviewed about search for missing resident blanket |
| CNA 3 | Certified Nursing Assistant | Interviewed about search for missing resident blanket |
| DON | Director of Nursing | Interviewed about catheter care and missing blanket process |
| SW | Social Worker | Interviewed about grievance process for missing resident belongings |
| IP | Infection Preventionist | Interviewed about COVID-19 testing deficiencies |
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