Above 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 Stonecreek during CMS and state inspections, most recent first.
A resident with a left foot wound and a history of orthopedic aftercare, toe amputation, and type 2 DM did not receive wound vac treatment as ordered due to delayed provision of wound vac supplies. After returning from wound clinic visits, notes documented that a wound vac was to be ordered and used on a specific schedule, with a physician order to start the wound vac ASAP to the left foot. A subsequent order specified that the wound vac must be in place and functioning with changes three times weekly and PRN. However, the wound vac could not be placed because supplies were not available. In interviews, an LPN and the DON reported that wound vacs and supplies from the contracted vendor typically arrived the same day, within hours, and not longer than a week, yet the DON was unable to explain why it took so long for this resident to receive the necessary supplies, resulting in failure to provide timely ordered wound care.
Two residents did not receive multiple ordered medications because drugs were out of stock or not delivered from the pharmacy. One resident with T2DM, orthopedic aftercare needs, and an amputation had repeated missed doses of glimepiride, Eucerin cream, and amitriptyline documented on the MAR, with notes stating medications were out of supply, on order, or not in stock, even after the resident questioned whether her antidepressant should still be given. Another resident admitted for post‑operative rehab with acute osteomyelitis and cellulitis had IV Piperacillin‑Tazobactam and Vancomycin ordered for infection but missed two scheduled Piperacillin‑Tazobactam doses and received a Vancomycin dose several hours late due to prescriptions not being faxed on arrival, fax transmission problems, and lack of delivered medication or emergency stock. Staff interviews described expectations to reorder medications several days before running out and to notify providers when medications are unavailable, but the documented missed doses and unavailability show these processes were not effectively carried out for these residents.
A resident admitted after hospitalization for osteomyelitis and sepsis with a left great toe amputation had hospital discharge orders for IV Cefazolin 2 g q8h for an extended course of therapy. At admission, staff misread the hospital order and entered the IV antibiotic in the system as a once-daily (q24h) dose, resulting in the resident not receiving any additional dose on the day of admission and only a single 2 g dose the following day, instead of the ordered q8h regimen. The resident reported to nursing staff multiple times that the antibiotic should be given q8h, and the DON later confirmed that the admitting nurse had misread the hospital order.
The facility failed to label an insulin pen and a vial of Lidocaine with open dates and improperly repackaged narcotics into medication cards. RNs acknowledged the medications were in use and should have been labeled, and the DON confirmed the proper procedures for labeling and wasting narcotics.
A resident who required maximum assistance for bed mobility and toilet use fell out of bed during a brief change performed by one CNA, resulting in contusions and emotional distress. The resident had requested a second staff member, but the CNA proceeded alone, leading to the fall. Interviews revealed that the resident was generally considered a two-person assist, highlighting a failure in communication and adherence to the care plan.
A resident with chronic pain and multiple medical conditions did not receive timely pain medication due to the facility running out of the prescribed narcotics and a non-functional emergency kit. The resident had to wait almost two hours for pain relief, causing significant distress and discomfort.
A resident with a history of major depressive disorder did not receive the necessary behavioral health services despite a physician's order and a referral for therapy. The resident expressed feelings of depression and a desire to see a therapist, but no action was taken to provide these services, and there was no documentation indicating that the resident had been seen by behavioral health services.
Delay in Wound Vac Supplies Resulting in Missed Ordered Treatment
Penalty
Summary
A resident with diagnoses including orthopedic aftercare, acquired absence of the left great toe, and type 2 diabetes was not provided wound vac supplies in a timely manner, resulting in a failure to implement ordered wound care according to professional standards and the resident’s care plan. On 6/5/25, a progress note documented that the resident had returned from a wound clinic appointment with instructions to order a wound vac, send it with the resident to the next appointment, and consider hyperbaric oxygen therapy. The note indicated that the DON and ADON were aware of these requests and orders. On 6/13/25, another progress note documented that the resident returned from an appointment with instructions that the wound vac was to be used on Monday, Wednesday, and Friday, with dressing changes every two days. The physician’s note/orders at that time stated to start the wound vac as soon as possible to the left foot, but also documented that they were unable to place the wound vac due to lack of supplies. On 6/16/25, a formal order was documented for a wound vac to the left foot, specifying that the wound vac should be in place and functioning, with changes on Monday, Wednesday, Friday, and as needed for wound healing. Despite these orders and the facility’s established process for obtaining wound vacs and supplies, the resident did not receive the necessary supplies in a timely manner. During interviews, an LPN stated that wound vacs were supplied by a contracted company and were brought the same day they were ordered, with all needed supplies. The DON stated that wound vacs arrived within two hours on the day they were ordered and that it would not take more than a week for a wound vac and supplies to be delivered, but she was unsure why it took so long for this resident to receive wound vac supplies. This discrepancy between the facility’s stated process and the actual delay in obtaining supplies led to the resident not receiving ordered wound vac treatment as prescribed.
Failure to Ensure Availability and Timely Administration of Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide routine and emergency medications as ordered for two residents, resulting in multiple missed doses due to medications being out of stock or not delivered. For one resident with type 2 diabetes, orthopedic aftercare needs, and an amputation of the left great toe, the medical record showed standing orders for glimepiride 4 mg at bedtime for diabetes, Eucerin Advanced Repair cream twice daily for dry, scaly skin on both lower extremities, and amitriptyline 25 mg at bedtime as an antidepressant. The MAR documented that glimepiride was not administered on multiple dates in September because the medication was not on hand, out of stock, or awaiting refill from the pharmacy. Progress notes repeatedly recorded that the glimepiride was unavailable, reordered, and awaiting delivery, and that staff were unable to give the medication because it was not in stock. For the same resident, the Eucerin cream was not administered on multiple dates in June and August. Progress notes documented that the cream was out of supply and on order. Additionally, amitriptyline was not administered on two consecutive dates in June. An eMAR note indicated there was “no med,” and a subsequent note documented that the medication was not available. A separate encounter note recorded that the resident sought verification that she was still supposed to receive her amitriptyline dose, and staff verified that the order was still active and that she should be receiving it nightly. Despite this, the MAR and notes show that the medication remained unavailable on at least one of those dates. The second resident was admitted for post‑operative rehabilitation with IV infusions and had diagnoses including orthopedic aftercare following an amputation, acute osteomyelitis of the right ankle and foot, cellulitis of the right lower limb, and type 2 diabetes mellitus. This resident had physician orders for Piperacillin‑Tazobactam 3.375 g IV every 6 hours and Vancomycin 1 g IV twice daily for infection. The MAR showed that the resident did not receive the ordered Piperacillin‑Tazobactam doses at two scheduled administration times and that the ordered Vancomycin evening dose was not given at the scheduled time but was instead administered several hours later. Nursing documentation stated that the resident was admitted after the scheduled dose time, that none of the prescriptions were faxed to the pharmacy on arrival, that faxes were not going through, and that the Piperacillin‑Tazobactam was not in the emergency kit and had not been delivered from the pharmacy. The resident later reported being very upset about not receiving antibiotics for several hours after they were due and expressed concern about his infection. Interviews with staff further described the facility’s processes and expectations for medication ordering and availability. An LPN stated that when a medication needed to be refilled, it was reordered in the electronic medical record to alert the pharmacy, and that residents should not go a week without a medication. The LPN also stated that nurses should notify the provider when a resident is out of medication and document those communications. An RN reported that medications should be reordered when there is about one week of supply left and that residents should never run out of medications, emphasizing that it is the nurse’s job to ensure medications are ordered and do not run out. The DON stated that medications should be reordered when there are five days left, that unavailable medications should be communicated to the provider for further direction, and that such issues should be documented and brought to nursing management. Despite these stated expectations, the records for both residents show repeated missed doses and documented unavailability of ordered medications.
Resident Did Not Receive IV Antibiotic at Ordered Frequency
Penalty
Summary
A resident admitted with orthopedic aftercare needs, an acquired absence of the left great toe, and type 2 diabetes had hospital discharge orders for IV Cefazolin 2 g every 8 hours for 50 days, with the last hospital dose given the morning of admission. Upon admission, facility staff entered the IV antibiotic order incorrectly into the system as 2 g IV every 24 hours/once daily instead of every 8 hours, and no additional dose was administered on the day of admission after the morning hospital dose. The Medication Administration Record showed the resident received only one 2 g dose on the day after admission, rather than the ordered every-8-hour regimen. Progress notes documented that a medication error occurred when the IV antibiotic was entered incorrectly and scheduled every 24 hours instead of every 8 hours, and that the resident reported not receiving the antibiotic the night of admission and told nursing staff multiple times that it was supposed to be given every 8 hours. The DON stated that the facility obtained medication orders from the hospital, that nursing managers were to review medications and orders within 72 hours of admission, and that nurses were instructed to have nursing management double-check all ordered medications. The DON reported that the admitting nurse misread the hospital order, leading to the incorrect frequency being entered and the resident not receiving the IV antibiotic as ordered every 8 hours.
Improper Labeling and Repackaging of Medications
Penalty
Summary
The facility did not label all drugs and biologicals in accordance with currently accepted professional principles. Specifically, an insulin pen and a vial of Lidocaine were found open and available for use without an open date, making it impossible to determine their expiration. Additionally, narcotics were improperly repackaged into narcotic cards. During observations, it was noted that a pre-filled pen of Lantus insulin and a vial of Lidocaine were not labeled with an open date. Registered Nurses (RNs) acknowledged that these medications were in use for residents and should have been labeled with an open date. The insulin pen was placed back into the medication cart for future use, and the Lidocaine vial was discarded by RN 2 after the observation. The Director of Nursing (DON) confirmed that medications should be labeled with an open date when taken out of the medication storage room, including insulin and Lidocaine. Furthermore, multiple instances of narcotics being repackaged into medication cards were observed. Medication cards containing Hydromorphone, Tramadol, Pregabalin, and Oxycodone were found with pockets taped, indicating that medications had been removed and possibly retaped back into the cards. RNs stated that the proper procedure was to waste narcotics with another nurse and not to retape them into the medication cards. The DON reiterated that nurses should waste narcotics with another nurse and not retape them into the medication cards, highlighting infection control issues and the inability to ensure the correct medication was retaped into the card.
Failure to Provide Adequate Supervision and Assistance Devices
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, Resident 41, who was dependent on staff and required maximum assistance for bed mobility and toilet use, had a brief change performed by one CNA, resulting in the resident rolling out of the bed, receiving contusions, and suffering emotional distress. The resident was admitted with multiple diagnoses, including fibromyalgia, hepatic encephalopathy, and muscle weakness, and was documented as requiring maximum assistance for bed mobility and other activities of daily living (ADLs). On the night of the incident, Resident 41 was being assisted by CNA 4, who raised the bed to waist level and attempted to change the resident's brief without additional help, despite the resident's request for a second staff member. The resident expressed fear of falling and requested to be moved back to the center of the bed, but CNA 4 proceeded to roll the resident further, resulting in the resident falling out of the bed and landing on the metal legs of a side table. The resident was transported to the hospital for evaluation and was found to have a chest contusion and shoulder bruise. Interviews with other CNAs and the DON revealed that Resident 41 was generally considered a two-person assist for all cares, including bed mobility and brief changes, due to her limited mobility and inability to grasp side rails. The DON and ADM initially stated that the resident was a one-person assist, but this was contradicted by other staff members who consistently reported that two people were needed to safely assist the resident. The incident highlighted a failure in communication and adherence to the resident's care plan, which specified the need for maximum assistance and the presence of two staff members during care activities.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident who required such services. Resident 41, who had a history of chronic pain and multiple medical conditions, was observed in significant pain and tearful after being flipped out of bed by a CNA the previous night. Despite the resident's verbal expression of pain and the presence of a physician's order for pain medication, the resident did not receive pain medication in a timely manner due to the facility running out of the prescribed narcotics and the emergency kit being non-functional. The resident had to wait almost two hours before receiving pain medication, causing her significant distress and discomfort. The RN on duty acknowledged the issue, stating that the lack of medication was due to other staff members not reordering it when needed, a common occurrence at the facility. The RN attempted to use the emergency kit, but it was not functioning, and the pharmacy had not yet delivered the additional pain medication prescribed by the emergency room. The resident's care plan included interventions for pain management, such as applying hot or cold packs, educating the resident on pain management, and responding immediately to any complaint of pain, but these were not effectively implemented in this instance. Interviews with the DON and CNAs confirmed that the facility had a single emergency kit for all residents, and if it was not working, medication had to be brought from the pharmacy. The DON admitted that the staff were expected to reorder medications when they got low and use other pain management options if available. The resident expressed frustration and confusion about why she had to wait so long for her pain medication, and the CNAs noted that the resident was always in pain and required very gentle care to avoid exacerbating her discomfort.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that Resident 29 received the necessary behavioral health care and services as per their comprehensive assessment and plan of care. Resident 29, who had a history of major depressive disorder, expressed feelings of depression and a desire to see a therapist. Despite being on antidepressants and having a physician's order for behavioral health evaluation and treatment, the resident did not receive the required behavioral health services. The resident had informed an unknown staff member about her need for therapy two to three months prior, but no action was taken to provide these services. The medical record review revealed that a referral for therapy was made on 2/2/24, but there was no documentation indicating that Resident 29 had been seen by behavioral health services. Interviews with the Social Services Director and the Director of Nursing confirmed that although a referral was made, there was no evidence that the resident received the necessary behavioral health care. The Director of Nursing mentioned that the nurse practitioner typically visits the facility the following Monday after an order is placed, but no notes from behavioral health services were received for Resident 29.
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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) |
|---|---|---|---|---|
| Monument Healthcare North Park | 0.8 mi | — | 0 | 0 |
| South Davis Specialty Care | 0.9 mi | ★★★★★ | 4 | 0 |
| Monument Healthcare Bountiful | 2.4 mi | ★★★★★ | 3 | 1 |
| Midtown Manor | 9.1 mi | ★★★★★ | 0 | 0 |
| City Creek Post Acute | 9.3 mi | ★★★★★ | 6 | 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.