Monument Healthcare Brigham City

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the resident environment remained free of accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. The deficiency involved two residents with repeated falls and wandering behavior in a locked unit where staff were not consistently present. The report states that the locked unit was left without nursing staff supervision for multiple periods of time, and one resident wandered into other residents’ rooms and other areas without staff intervention being observed. One resident had diagnoses including senile degeneration of the brain, muscle weakness, gait and mobility abnormalities, and unspecified dementia. He was observed multiple times with his bed in an elevated position and his call light out of reach or pinned to the wall. He was also observed leaning to one side in his wheelchair, appearing sleepy, and remaining in bed with the call light inaccessible. His record showed multiple falls over time, including falls from the wheelchair, from beside the bed, and while pulling on furniture or bed components. After several of these falls, the interventions documented were repeated or reused, including lowering the bed after cares, following the falling leaf program, laying the resident down after meals, placing a foam cushion on the wheelchair, moving him to a shared room, and posting a sign to help him to bed after meals. The other resident had diagnoses including unsteadiness on feet, history of falling, and Alzheimer’s disease. He was observed pushing against an exit door, entering another resident’s room and bathroom, trying to exit the locked unit, lying on a fall mat, getting out of bed and walking unassisted to the bathroom, going through another resident’s belongings, attempting to remove a fire extinguisher, and urinating on another resident’s bathroom floor. Staff were not observed in the hallways or at the nurse’s station during several of these events. His record showed multiple falls with interventions such as the falling leaf program, a new wheelchair, the recreation cart, bright colored tape on wheelchair brakes, medication review, removing rugs, and neurological checks. One fall had no intervention documented, and several documented responses were treatments or monitoring rather than new fall-prevention interventions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Food was not stored, prepared, distributed, and served in accordance with professional standards in the kitchen. During an initial tour, vents above the grill were observed with dust on them, large bins labeled oatmeal, powdered sugar, flour, and sugar were soiled on the outside, celery seed and Mediterranean style ground oregano were open to air, and the juice machine compressor and tray had crumbs and debris on them. On a follow-up observation, the same conditions were again observed, including dust on the vents, soiled storage bins, and crumbs and debris on the juice machine compressor and tray. Hand hygiene practices observed in the kitchen did not follow the posted handwashing instructions. The Dietary Manager was observed washing hands for less than 20 seconds on one occasion and for 4 seconds on another, then putting on gloves and handling pie, touching the pie and plating it with gloved hands. The Dietary Manager was also observed removing gloves, touching certificates on the wall, and then donning gloves again without performing hand hygiene before continuing to plate pies. [NAME] 1 was also observed washing hands for less than 4 seconds on one occasion and for 10 seconds on another, despite a posted sign instructing handwashing for at least 20 seconds under running water at least 110 degrees.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. On 6/29/26, resident 29 was observed passing out clothing protectors in the dining room. Resident 6 was observed to wheel herself toward the exit of the dining room when resident 29 placed a clothing protector on her. Resident 6 stated she had to go to the bathroom, then entered her bathroom with the clothing protector and returned to the dining room with the same clothing protector still on before eating. Also on 6/29/26, resident 4 was observed in the dining room when CNA 5 picked up the resident’s nasal cannula from the floor and placed it in the resident’s nose without sanitizing it first. On 7/1/26, two CNAs were observed taking the Hoyer lift from resident 26’s room to resident 29’s room, and the lift was then placed in the hallway without being sanitized between resident uses. The DON stated the oxygen tubing should have been replaced after being on the floor, resident 6 should have been provided a new clothing protector before eating, and staff should have wiped down the Hoyer lift with a sanitizer cloth between resident use.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide safe, appropriate pain management for a resident with chronic pain when a nurse did not timely assess and administer a prescribed PRN opioid after repeated requests from the resident and alerts from multiple CNAs. Resident 33 had diagnoses including muscular dystrophy, major depressive disorder, moderate dementia without behavioral disturbance, and personality disorder, and her care plan identified chronic pain with a goal to remain free from pain or at a level of discomfort acceptable to her. Her physician orders included oxycodone-acetaminophen 7.5-325 mg every 6 hours as needed for moderate pain and acetaminophen 325 mg, 2 tablets every 8 hours as needed for pain. On the night of the incident, Resident 33 was assisted to bed and repeatedly requested her pain medication while also making statements about killing people with guns, a BB gun, a paint gun, and a water gun. Multiple CNAs reported both the resident’s statements and her request for pain medication to RN 1. RN 1 entered the room to address the threatening statements, but the resident became hostile and told the nurse to leave. Documentation showed no pain assessment, no contact with the provider or facility leadership, and no documented response to the resident’s repeated requests for pain medication at that time. Resident 33 did not receive pain medication until approximately 4:09 AM, more than 18 hours after the prior dose and more than 4 hours after the initial request during the night. The resident reported that she had been in agony for hours and that the nurse refused to give her the medication because of the statements she had made. CNA statements and RN 1’s own account confirmed that the resident asked for the medication multiple times before it was finally administered. The DON stated that pain must be treated subjectively based on the resident’s report and that if a nurse had safety concerns about giving a narcotic, the nurse must contact the on-call medical provider or facility clinical leadership for guidance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to immediately consult the resident’s physician when there was a significant change in the resident’s psychosocial and behavioral status involving homicidal threats, and the resident’s ordered PRN pain medication was delayed. Resident 33 was admitted with diagnoses including muscular dystrophy, major depressive disorder, dementia, and personality disorder, and had an order for oxycodone-acetaminophen every 6 hours as needed for moderate pain. The resident also had documented ongoing mouth pain that frequently interfered with sleep, therapy, and daily activities. During the night of 6/25/26 into 6/26/26, nursing assistants reported that Resident 33 was making repeated statements about killing people and using guns. RN 1 entered the room, told the resident the threats were serious, and said police would be called if further statements were made. CNA documentation and staff statements indicated the resident also requested pain medication multiple times during the night, but RN 1 did not administer the medication at that time and did not notify the physician or DON during the shift. RN 1 later stated she was concerned about whether it was safe to give an opioid while the resident was making threats, and the pain medication was not given until 4:09 AM. The DON confirmed that if a resident’s ordered medication was withheld or delayed due to behavioral concerns, the nurse must immediately notify the on-call provider for guidance, and verified the physician was not notified until the morning of 6/26/26. The facility’s internal investigation also stated the medical provider was not timely notified after the resident exhibited concerning behavior posing a safety risk to others, and that the nurse did not feel comfortable administering the opiate medication until she spoke with the resident about the threats. The facility policy required the nurse to assess and document pain and current behavior and report findings to the physician.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure that each resident's drug regimen was free from unnecessary drugs. Resident 21, who was admitted with diagnoses including anxiety disorder, insomnia, and Alzheimer's, had a physician order started on 11/4/25 for trazodone HCl 100 mg by mouth at bedtime for insomnia. Review of the resident's Medication Administration Record and Treatment Administration Record for May and June 2026 showed that hours of sleep were not being monitored. During an interview on 7/1/26, the DON stated that trazodone required monitoring for antidepressant use and hours of sleep unless it was being used only for depression, and confirmed that Resident 21 was taking trazodone for insomnia and sleep and was not having hours of sleep monitored.

Penalty

Inspection fine: $10,166

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with severe dementia and urinary incontinence was left in a wet brief for an extended period, resulting in a rash and excoriation to the groin area. The resident was unable to communicate her needs and relied on staff for incontinence care. On the evening in question, the assigned CNA failed to perform the required two-hour checks and did not change the resident's brief for approximately eight hours. When oncoming staff arrived, they found the resident saturated with dried and wet urine up to her shoulders, and the nurse confirmed the resident's condition and documented skin breakdown. Multiple staff interviews revealed that the CNA assigned to the resident gave conflicting accounts of when care was last provided, initially claiming to have changed the resident multiple times, then admitting she had not done so since the afternoon. The CNA also blocked other staff from entering the resident's room and yelled at a coworker who confronted her about the lack of care. Other CNAs and nurses stated that routine practice was to check and change residents at least every two hours, and that leaving a resident in a wet brief could quickly lead to skin breakdown or infection. The facility's policy required regular incontinence care and monitoring to prevent neglect and harm. Staff interviews confirmed that the resident never refused care and that there were standing orders for frequent checks due to her incontinence and cognitive impairment. The failure to provide timely incontinence care directly resulted in physical harm to the resident, as evidenced by the documented skin issues and the observations of multiple staff members.

Penalty

Inspection fine: $36,436

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from abuse, resulting in an Immediate Jeopardy citation. A resident with a history of dementia and cognitive impairments was found missing by staff, and after a search, was discovered exiting a locked therapy room. The resident made statements indicating that a male staff member engaged in sexual actions with her. The therapy room was inaccessible to staff, and the resident was found pale, nauseated, and disoriented, with therapy paperwork in hand. Interviews with staff revealed that the therapy room was locked, and the resident was missing for approximately 20 minutes. Staff observed the resident exiting the therapy room, appearing sick and disoriented. The resident later disclosed to staff that she and a male staff member attempted to engage in sexual activity, which was reportedly consensual according to the resident. However, the resident's cognitive impairments raised concerns about her ability to consent. The male staff member, a Physical Therapy Assistant, was found in the facility after hours, contrary to previous instructions. Staff reported that the therapy room was usually unlocked, and the male staff member's presence in the facility after hours had been a concern. The facility's failure to ensure the safety and security of the resident, as well as the lack of access to the therapy room, contributed to the deficiency.

Removal Plan

• Resident and staff member were separated.
• Police contacted upon suspicion.
• Resident assessed; no injury noted.
• Notification to Physicians, POA, Incident reported by administrator to DHS, APS, Ombudsman.
• Resident interviewed with administrator.
• Hospital evaluation completed, no trauma noted.
• Resident care plan reviewed and updated as needed.
• Provider to assess/evaluate residents including medication review.
• Social Services wellness visits to be completed for resident and PRN.
• Behavioral health visit requested with local mental health provider.
• Therapy staff member was immediately placed on administrative leave, facility keys/badge provided to administrator.
• Therapy staff member was questioned and released by the police, pending potential charges.
• Employee file was reviewed.
• Therapy staff member will not return to the facility.
• Regional Director of Operations spoke to Therapy Regional Director and informed him that staff are not to stay in the facility after normal business hours without the approval of the facility administrator.
• Facility will ensure the therapy staff working in the facility have background checks (DACS) that are connected to the facility.
• All residents interviewed by administrator/designee to assess potential for abuse/neglect allegations.
• Locks will be removed from all doors and/or Master Key accessible to charge nurse on medication cart.
• Staff Members will not remain in the facility after normal business hours without the approval of the facility administrator.
• Administrator, DON and RNC reviewed Abuse & Neglect Policy.
• Administrator, DON and IDT were educated by RNC regarding Abuse & Neglect Policy.
• Administrator/DON/designee will complete Abuse & Neglect education with all staff.
• Education including post-test initiated for all facility staff on Abuse/Neglect.
• All employees will be educated at start of their next shift or if no scheduled shift by all staff meeting.
• The DON/designee will review incidents of sexually inappropriate behavior to ensure appropriate interventions are implemented and no trends are noted.
• The Administrator/designee will conduct random resident & staff interviews to ensure the Abuse & Neglect Policy have been followed and allegations have been investigated and reported.
• The facility administrator/designee will do random facility visits during off hours to ensure that only staff clocked in and assigned to be working are in the facility and that the charge nurse has a Master Key to all locked doors in the facility.
• The Administrator/designee will review employee files (including contracted therapist) to ensure they have completed abuse training, verification of license and background checks (DACS) is connected to the facility.
• Medical Director was informed of the incident and QAA Review & Recommendations.
• Results will be reported to the QAA committee from monitoring and follow-up.

Penalty

Inspection fine: $36,436

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial tour of the kitchen, it was observed that the dish machine's washing and rinse temperatures were below the manufacturer's required levels, with washing temperatures recorded at 110°F and rinse temperatures at 120°F. The Dietary Manager (DM) acknowledged the issue, stating that the dish machine temperatures fluctuated, especially during resident showers, and that the machine needed to be run multiple times to reach the appropriate temperature. Additionally, there were no sanitizer strips available to test the solution, and the DM was unable to locate any strips. A follow-up tour revealed continued non-compliance, with dish machine temperatures still below the required levels, and the sanitizer level was recorded at 100 PPM. The Low Temperature Dish Machine Log showed inconsistencies, with the last recorded temperature on the 14th, despite the follow-up occurring on the 16th. The Dietary Aide (DA) confirmed the low temperatures and admitted to documenting temperatures inaccurately. The Vendor Consultant, who visits the facility monthly, confirmed the need for the dish machine to reach temperatures above 120°F for both wash and rinse cycles and suggested changes to the logging process to include temperatures for breakfast, lunch, and dinner.

Penalty

Inspection fine: $36,436

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for its residents. During interviews, several residents expressed dissatisfaction with the food quality. One resident found the food unappealing and unappetizing, while another resident, who was sensitive to spices, reported that the food had been too spicy. Another resident mentioned the lack of substitutes, and yet another resident expressed a need for better food and was restricted to a limited amount of juice per day. Observations of the facility's tray line revealed issues with food preparation and presentation. A test tray contained bland and slimy turkey and ham with marinara sauce, pureed broccoli with chunks, and a dessert with raw cake on top. Further observations on a different day showed that the food served was not at an appetizing temperature, with pork, stuffing, broccoli, and coffee all served below ideal temperatures. The pork was tough and bland, the stuffing was mushy, and the cake was dry. Interviews with the Dietary Manager and a Vendor Consultant revealed that the alternative meal was not served to residents, and the turkey and ham had been prepared days earlier. The Vendor Consultant noted that the cook ran out of gravy and added water to the stuffing after it had been sitting on the steam table. These actions and inactions contributed to the deficiency in providing quality meals to the residents.

Penalty

Inspection fine: $36,436

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide suitable and nourishing alternative meals and snacks for residents who wanted to eat at non-traditional times or outside of scheduled meal service times. Observations revealed that for 5 out of 27 sampled residents, only saltine crackers were consistently offered as snacks. Containers at both the north and south nurses stations were observed to contain primarily saltine crackers, with some instances of crackers being open to air. Although there were occasional offerings of fruits and other snacks, these were not consistently available, and the restocking of snacks appeared to be irregular. Interviews with residents indicated dissatisfaction with the snack offerings. One resident mentioned that snacks were usually filled once a week and that the availability of better snacks seemed to coincide with visits from important individuals. Another resident expressed a desire for snacks to be offered at night to avoid going to bed hungry. Staff interviews revealed that the responsibility for restocking snacks was assigned to the evening shift, but there was no consistent routine for ensuring a variety of snacks were available. This inconsistency in snack availability and variety led to the deficiency noted by the surveyors.

Penalty

Inspection fine: $36,436

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a clean, comfortable, and homelike environment, as evidenced by persistent strong odors throughout various areas, including hallways and the dining room. Observations made over several days revealed a strong urine odor, as well as bowel movement and body odors, in multiple locations within the facility. Specific instances included a brown substance on a wheelchair seat and back, contributing to the unsanitary conditions. Interviews with staff, including a registered nurse, certified nursing assistants, and a housekeeper, confirmed the presence of these odors, with some staff acknowledging that certain residents contributed to the odors due to incontinence issues and refusal to be changed. Staff interviews revealed that the odors were a known issue, with some staff attempting to mitigate the smell using air fresheners. However, the odors persisted, particularly in areas where residents with incontinence issues were located. The housekeeper noted that certain rooms consistently had odors, often due to wet briefs being disposed of in bathroom trash cans. Despite these efforts, the facility's failure to adequately address and manage these odors resulted in a deficiency in maintaining a safe, clean, and homelike environment for residents.

Penalty

Inspection fine: $36,436

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement written policies and procedures that effectively prohibited and prevented abuse, neglect, and exploitation of residents. This deficiency was identified when a Physical Therapy Assistant (PTA) was found not to be connected to the facility through the Direct Access Clearance System (DACS), which is a requirement for ensuring that staff members are properly screened and linked to the facility. The PTA's employee file contained an offer letter for another facility, and there was no documentation indicating employment with the facility being surveyed. The information available was from a contract rehabilitation company, suggesting a lack of proper documentation and oversight. During an interview, the Administrator confirmed that a background screening was completed for the PTA, and no issues were found. However, the Background Processing Manager (BPM) at the State Survey Agency revealed that while the PTA was eligible for work, they had not been connected to the facility in the DACS. This oversight indicates a failure in the facility's process to ensure that all staff members are appropriately linked to the facility, which is a critical step in preventing abuse and ensuring resident safety. The facility's policy on preventing abuse, neglect, and exploitation, dated 11/2017 and revised in 9/2022, outlines comprehensive guidelines for screening, training, prevention, identification, investigation, protection, and reporting. Despite these guidelines, the failure to connect the PTA to the facility in the DACS represents a significant lapse in the implementation of these policies. This deficiency highlights the need for the facility to ensure that all staff, including contracted and temporary staff, are properly screened and documented in accordance with established procedures.

Penalty

Inspection fine: $36,436

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which resulted in multiple falls, a skin tear, and hip pain. The resident, who was admitted with several diagnoses including surgical amputation and chronic pain syndrome, was identified as being at risk for falls. Despite this, the care plan interventions, such as changing to a bariatric bed, were not implemented effectively. The resident experienced several unwitnessed falls, and although interventions like a floor mat and medication review were discussed, they were not timely or adequately executed. The resident's care plan was revised to include a bariatric bed, but this intervention was not implemented, as confirmed by staff interviews and the resident's own account. The resident continued to fall, sustaining injuries, and expressed frustration over not receiving the requested larger bed. Staff members, including CNAs and LPNs, were unaware of the care plan interventions, indicating a lack of communication and follow-through on the care plan updates. Interviews with the DON and other staff revealed discrepancies in the implementation of the care plan. The DON believed the resident had received a bariatric bed, but it was later discovered during the survey that this was not the case. The lack of proper communication and execution of the care plan interventions contributed to the resident's repeated falls and injuries, highlighting a deficiency in the facility's care planning and implementation processes.

Penalty

Inspection fine: $36,436

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the resident environment was free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for one resident. This resident, who had a history of falls and was at risk due to gait and balance problems, experienced multiple falls. Despite the resident's request for a larger bed to prevent falls, the facility did not provide a bariatric bed until after several incidents occurred. The resident, who had a history of surgical amputation, diabetes, and other health issues, was admitted to the facility and had a care plan indicating a risk for falls. The care plan was revised to include a bed change to a bariatric bed, but this intervention was not implemented in a timely manner. The resident experienced several unwitnessed falls, resulting in minor injuries and complaints of hip pain, yet the facility did not provide the necessary assistance device promptly. Interviews with staff revealed a lack of awareness and implementation of interventions to prevent falls. The DON initially stated that a bariatric bed was provided, but later confirmed that the resident did not have one. The facility's failure to provide the appropriate bed and timely interventions contributed to the resident's repeated falls and injuries.