Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Monument Healthcare Bountiful during CMS and state inspections, most recent first.
A resident with significant mobility limitations fell from a Hoyer lift during a transfer when only one CNA assisted, contrary to policy requiring two staff. The lift was missing required safety latches, and the sling was not properly secured, resulting in the resident sustaining a fracture. Staff interviews and observations confirmed lapses in following procedures and equipment checks.
A resident with multiple medical conditions sustained a fall from a Hoyer lift resulting in a fracture, but the incident was not reported to the SSA within the required timeframe, and APS was not notified. The DON confirmed the delay in reporting and lack of investigation for possible neglect, leading to a deficiency in mandated reporting.
A resident with multiple medical conditions fell from a Hoyer lift during a transfer, resulting in pain and injury. The facility's abuse investigation lacked documentation of interviews with the staff involved and the resident, and the incident date was recorded incorrectly. The DON confirmed that the investigation records were incomplete and did not demonstrate a thorough review to rule out neglect.
A resident with cerebral palsy and functional quadriplegia was being pushed in a wheelchair by a CNA without footrests in place, resulting in the resident's foot catching on the ground and a fall that caused facial abrasions, a lip laceration, and other minor injuries. The incident highlighted a failure to provide adequate supervision and accident prevention during wheelchair transport.
A nurse mistakenly administered a resident's roommate's medications, including acetaminophen, senna, trazodone, and extended release morphine. The error was promptly reported, the resident was monitored for adverse effects, and no changes in condition were observed during follow-up assessments.
A resident with cognitive impairment and mobility issues slid out of her wheelchair during transport, resulting in a femur fracture. The van driver did not call emergency services and continued to the appointment. Upon return, the incident was reported to the Admissions Coordinator and a nurse, but the resident was not assessed or documented in the medical record. The injury was discovered days later after the resident complained of pain, revealing a lack of supervision and communication within the facility.
A resident with multiple diagnoses, including chronic pain and pressure ulcers, did not receive adequate pain management during wound care. Despite having orders for Acetaminophen and Morphine, the resident was not premedicated, leading to significant discomfort. Staff interviews and observations confirmed the oversight, with the RN admitting to not administering pain relief as per protocol. The DON acknowledged the failure to follow pain management procedures, resulting in a deficiency in care.
A resident with multiple health conditions fell from a wheelchair during transportation, resulting in a fracture. The facility failed to report the incident to the SSA within the required timeframe. Despite the resident's ongoing pain and eventual diagnosis of a fracture, the incident was not reported, highlighting a communication breakdown between the DON and the Administrator.
Two residents' MDS assessments were inaccurately completed, failing to reflect hospice services and PASRR Level II status. A resident receiving hospice care was not coded as such, and another with a PASRR Level II indicating serious mental illness was incorrectly documented. The MDS Coordinator did not thoroughly verify these statuses, leading to documentation errors.
A resident with a complex medical history experienced knee and hip pain, prompting x-rays to be ordered. While reports for the left knee and hips were documented, the right knee x-ray report was missing from the medical record, despite a critical fracture being reported. The DON acknowledged the oversight, and the missing report was later provided by the Regional Clinical Operations Director.
A facility failed to maintain proper infection control during a wound care procedure for a resident with pressure ulcers. The RN did not perform hand hygiene between glove changes and handled sterile supplies with bare hands, contrary to facility policy. The resident, who had multiple medical conditions and was dependent on staff, expressed pain during the procedure. The DON confirmed the breach in protocol, highlighting a deficiency in the infection prevention and control program.
Resident Fall Due to Improper Hoyer Lift Use and Missing Safety Latches
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all transfers and activities of daily living due to multiple medical conditions including hemiplegia, diabetes, and a history of stroke, sustained a fall from a Hoyer lift during a transfer from bed to wheelchair. The incident happened during a one-person assisted transfer, despite facility policy and manufacturer guidelines requiring at least two staff members for safe operation of the mechanical lift. The resident was found on the floor with pain in the hip and knee, and later diagnosed with a fracture after being transferred to the hospital due to persistent, severe pain. Investigation revealed that the Hoyer lift used during the incident was missing safety latches on the cradle hooks, which are required by the manufacturer to prevent sling straps from slipping off. Staff interviews confirmed that the sling was not properly secured, with one of the straps not attached to the lift, and that the CNA operating the lift did not request assistance or verify the secure placement of all straps. The CNA involved admitted to not being familiar with the sling and noted that the absence of safety latches made it easier for straps to come off the hooks. Another CNA present at the time also failed to inspect the sling for proper placement, assuming the other staff member had done so. Observations and interviews further confirmed that both Hoyer lifts in the facility were missing some or all of the required safety latches, and that staff were not consistently following procedures to ensure equipment was in good working condition and that transfers were performed with adequate supervision. The facility's own policy and the manufacturer's instructions both require thorough inspection of the lift and sling, proper attachment of all straps, and the presence of two trained staff during transfers. These requirements were not met at the time of the incident, directly leading to the resident's fall and injury.
Failure to Timely Report Suspected Neglect Following Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to report an alleged violation involving neglect within the required 24-hour timeframe. Specifically, a resident with multiple complex medical conditions, including type 2 diabetes mellitus, right femur fracture, hemiplegia, and respiratory failure, sustained a fall from a Hoyer lift during a one-person assisted transfer. The incident resulted in a fracture, and the event was documented by the Interdisciplinary Team as a fall from the lift. However, the State Survey Agency (SSA) was not notified of the incident until approximately seven days after it occurred, and there was no documentation indicating that Adult Protective Services (APS) had been notified at all. During an interview, the Director of Nursing (DON) acknowledged the regulatory requirement to report suspected abuse or neglect to the state within two hours and confirmed that the facility did not investigate the incident for possible neglect in a timely manner. The DON also stated that APS was not notified and could not provide a reason for this omission. The failure to report the incident as required and to notify the appropriate authorities constituted a violation of mandated reporting protocols.
Failure to Document Thorough Investigation After Resident Fall
Penalty
Summary
A deficiency was identified when the facility failed to provide evidence of a thorough investigation into an allegation of neglect following a fall incident involving a resident. The resident, who had multiple complex medical diagnoses including type 2 diabetes, right femur fracture, asthma, major depressive disorder, hemiplegia, respiratory failure, and cognitive communication deficit, sustained a fall from a Hoyer lift during a one-person assisted transfer. The incident resulted in complaints of pain and a visible injury, prompting an abuse investigation and notification to the State Survey Agency. The facility's abuse investigation documentation was incomplete, lacking records of interviews with the staff members involved in the transfer and the resident. Additionally, the investigation summary referenced an interview with the resident, but no documentation of this interview was found. The date of the incident was also incorrectly documented in the investigation. The Director of Nursing confirmed that the investigation records did not contain the necessary interviews to rule out neglect, and it was not evident from the documentation that a thorough investigation had been conducted.
Resident Fall Due to Lack of Wheelchair Footrests During Transport
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral palsy, functional quadriplegia, contractures, and balance deficits was being transported in a wheelchair by a CNA without the use of footrests. The resident, who was able to self-propel using one foot, was being pushed by staff when her foot caught on the ground, causing her to fall forward out of the wheelchair. As a result, the resident sustained abrasions to her face and wrist, a skin tear, and a laceration to her lip. She also experienced pain in her back, mouth, face, and chest, and exhibited shallow breathing following the incident. Medical records indicated that the resident was unable to brace herself during the fall due to her physical limitations. The incident required emergency medical services, and the resident was transferred to a hospital for evaluation. Subsequent assessments confirmed no fractures, but superficial injuries were present. The deficiency was identified through observation, interviews, and record review, which confirmed that the resident did not have appropriate supervision and safety measures in place to prevent the accident during wheelchair transport.
Medication Error: Resident Administered Roommate's Medications
Penalty
Summary
A nurse administered the incorrect medications to a resident by giving her the medications intended for her roommate. The medications given in error included acetaminophen 325mg, senna 8.6mg, trazodone 50mg, and extended release morphine 15mg. The incident was documented in the resident's medical record, and the nurse notified the physician, who provided instructions to hold the resident's scheduled Tylenol, senna, and trazodone. The nurse also contacted the resident's emergency contact and initiated monitoring for any adverse effects. Following the medication error, nursing staff conducted additional assessments each shift to monitor the resident for any changes in condition. Throughout the monitoring period, the resident's condition remained at baseline with no noted changes. The nurse involved reported the error to the nurse manager and followed instructions to check for allergies and perform neurological checks. The incident was the only medication error reported in the facility within the past 60 days.
Resident Injury Due to Inadequate Supervision During Transport
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident, who slid out of her wheelchair during transport and sustained a femur fracture. The resident, who had a history of hemiplegia, hemiparesis, and moderate cognitive impairment, was being transported to a medical appointment when the incident occurred. The van driver reported that the resident informed him she was sliding out of her wheelchair, prompting him to stop and seek assistance from a nearby school. Despite the resident being partially suspended by the seatbelt, the driver did not call emergency services, as per company policy, and continued to the appointment. Upon returning to the facility, the van driver informed the Admissions Coordinator and a nurse about the incident. However, the nurse did not assess the resident or document the occurrence in the medical record. The resident later complained of pain, leading to x-rays that revealed a fracture. The facility's staff, including the DON and ADON, were not immediately informed of the incident, and the resident's condition was not promptly addressed, resulting in a delay in identifying the injury. Interviews with facility staff revealed communication breakdowns and a lack of proper documentation and assessment following the incident. The SLP was informed by the resident about the fall and reported it to the DON, but did not document this communication. The RN on duty at the time of the incident did not perform an assessment or document the event, contributing to the oversight. The facility's failure to ensure proper supervision and communication led to the resident's injury going unaddressed for several days.
Inadequate Pain Management for Resident During Wound Care
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident 42, who required such services. Resident 42 was admitted with multiple diagnoses, including chronic pain and pressure ulcers. Despite having physician orders for pain management, including Acetaminophen and Morphine, the resident did not receive pain medication prior to or after wound care treatments. The resident reported a pain level of 8 out of 10, yet the medication administration record showed inconsistent documentation of pain scores and administration of pain relief. During an observation, Resident 42 expressed pain during wound care, moaning and vocalizing discomfort, yet was not premedicated with pain relief as per the facility's protocol. The Registered Nurse (RN) involved acknowledged the oversight and admitted to not administering pain medication before or after the wound care session. The Director of Nursing (DON) confirmed that pain medication should be administered 30 to 40 minutes prior to wound care, but this protocol was not followed. Interviews with staff revealed that Resident 42 was dependent on staff for care and experienced pain with movement, particularly in the right knee and heels. Despite having orders for pain evaluations every shift and the availability of Morphine for severe pain, the resident's pain management was inadequate, leading to unnecessary suffering during wound care procedures. The facility's failure to adhere to pain management protocols and physician orders resulted in a deficiency in providing appropriate care for Resident 42.
Failure to Report Resident Fracture Incident
Penalty
Summary
The facility failed to report an incident involving a resident who sustained a fracture during transportation. Resident 20, who has a medical history including hemiplegia, heart disease, diabetes, and cognitive deficits, fell out of a wheelchair while being transported to an appointment. The incident was initially noted by a speech language pathologist and later by the Assistant Director of Nursing (ADON), who observed an abrasion on the resident's knee. Despite these observations, the incident was not reported to the State Survey Agency (SSA) as required. The resident continued to experience pain, leading to further assessments and x-rays. Initially, x-rays of the left knee and hips showed normal results, but subsequent x-rays revealed a critical fracture in the right leg/knee. The resident was then sent to the emergency room for treatment. Despite the discovery of the fracture, the facility did not report the incident to the SSA within the required timeframe. Interviews with the Director of Nursing (DON) and the Administrator revealed a lack of communication and understanding regarding the reporting requirements. The DON believed the incident was not reportable until the fracture was confirmed, and the Administrator acknowledged that no report was filed with the SSA. The Administrator stated that the incident should have been reported within 24 hours once the fracture was identified, but this did not occur.
Inaccurate MDS Assessments for Hospice and PASRR Status
Penalty
Summary
The facility failed to accurately reflect the status of two residents in their Minimum Data Set (MDS) assessments, leading to deficiencies in the documentation of hospice services and Preadmission Screening and Resident Review (PASRR) Level II status. Resident 22, who was receiving hospice services, was not coded as such on two quarterly MDS assessments and an annual MDS assessment. Despite the hospice start of care date being documented in the resident's medical record, the MDS Coordinator did not identify this in the daily census or the resident's medical record, where the resident was listed as private pay. Resident 27, who had a PASRR Level II assessment indicating serious mental illness, was not accurately coded in the MDS assessment. The MDS Coordinator relied solely on the PASRR Letter of Determination, which did not explicitly state the presence of a serious mental illness, rather than reviewing the full PASRR Level II evaluation. This led to an incorrect 'No' response in the MDS assessment regarding the resident's PASRR status, despite the evaluation documenting a serious mental illness. The MDS Coordinator's process for completing assessments involved a schedule distributed to department heads, with various sections of the MDS being completed by different staff members. However, the MDS Coordinator did not verify the hospice status or PASRR Level II status through comprehensive review of the residents' medical records, leading to inaccuracies in the MDS assessments for both residents.
Missing X-ray Report in Resident's Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident, specifically by not filing a signed and dated x-ray report for the resident's right knee. The resident, who had a complex medical history including hemiplegia, atherosclerotic heart disease, and type 2 diabetes, was experiencing bilateral knee and hip pain. An x-ray was ordered for both knees and hips, and while the results for the left knee and hips were documented, the report for the right knee was missing from the medical record. The deficiency was identified during a review of the resident's medical records, which revealed that the x-ray report for the right knee was not present, despite a critical fracture being reported to the facility. The Director of Nursing acknowledged the oversight, stating that the facility had not received a printed report for the right knee, although the Regional Clinical Operations Director later provided a copy of the missing report. This lapse in documentation highlights a failure in the facility's process for ensuring all diagnostic reports are properly filed in the resident's medical record.
Infection Control Deficiency in Wound Care Procedure
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and PPE usage during a wound care treatment for a resident. The resident, who had multiple medical conditions including dementia and pressure ulcers on both heels, was observed receiving wound care from a registered nurse (RN). During the procedure, the RN did not adhere to proper hand hygiene protocols, such as failing to perform hand hygiene between glove changes and handling sterile supplies with bare hands. The resident, who was dependent on staff for care and had a moderate cognitive impairment, expressed pain during the wound care procedure. The RN was observed to don and doff gloves without performing hand hygiene in between, and handled sterile gauze with bare hands, which compromised the sterility of the supplies. The RN acknowledged the need for hand hygiene between glove changes but did not follow through during the procedure. The Director of Nursing (DON) confirmed that the facility's policy required hand hygiene before donning gloves and between glove changes, especially when moving from a dirty to a clean area. The facility's policy on hand hygiene, which was last revised in February 2024, was not adhered to during the observed wound care, leading to a deficiency in the infection prevention and control program.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bountiful
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Davis Specialty Care | 1.9 mi | ★★★★★ | 4 | 0 |
| Monument Healthcare North Park | 2 mi | — | 0 | 0 |
| Monument Healthcare Stonecreek | 2.4 mi | ★★★★★ | 3 | 0 |
| Midtown Manor | 6.7 mi | ★★★★★ | 0 | 0 |
| Monument Healthcare Cottonwood Creek | 7.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.