Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Failure to Provide Ordered Pressure Ulcer Interventions: A resident with multiple stage 4 pressure ulcers and dependence for mobility was repeatedly observed without ordered heel off-loading boots, compression socks, or effective heel protection, with heels resting on the mattress or a pillow and dressings sticking to the sheets. The record also showed a delay in wound vac availability for the sacral wound, while staff interviews confirmed the resident needed booties and compression socks and that an RN had not been trained on wound vac use.
A facility failed to ensure that residents with medications at the bedside were properly evaluated for safe self-administration. Several residents had pills or inhalers in their rooms without a current order or self-medication evaluation, and staff documented that some residents were not safe to self-administer due to cognitive deficits, inability to identify the medications, or excessive use of inhalers. One resident was found with multiple medications at the bedside and could not state what they were, while another was using albuterol far more often than ordered.
Unnecessary urinary catheters and improper PureWick use. Three residents had urinary catheters in place without a documented indication for continued use, and staff were unaware of why the catheters were needed. One resident with diagnoses including fibromyalgia, cirrhosis, and hepatic failure had a PureWick in place, but the tubing was observed draped over the head of the bed instead of positioned to drain properly, and staff described inconsistent training and placement practices.
Missing laboratory reports were found in the clinical records for three residents. One resident with renal dialysis, diabetes, and anemia in CKD had ordered CBC and other admit labs with no results located; another resident with kidney failure, thrombocytopenia, and CMML had ordered CBC, BMP, CMP, and other labs with no results located; and a third resident with cirrhosis, hepatic failure, anxiety, depression, and chronic pain had multiple ordered LFP, BMP, CBC, INR/PT, prealbumin, and UA/C&S results missing from the chart. The RNC stated the lab results had to be obtained from the hospital or portal and were not in the residents’ records.
Food items were found undated, expired, and open to air in the kitchen freezer and refrigerator, and expired yogurt was also found in resident refrigerators. During lunch tray line, kitchen staff were observed touching multiple surfaces without changing gloves, and a cook used the same gloved hands to handle a hamburger bun and then gluten free bread for a gluten free resident.
Failure to Supervise Residents at Risk for Elopement: Two residents who were at risk for wandering or elopement left the facility without proper supervision. One resident with moderate cognitive impairment left in an Uber and later called his daughter because he did not know how to get back, and another resident who required supervised LOA left unaccompanied and was reported missing until he returned on his own. Records showed missing or unclear elopement assessments and no care plan for one resident, and no care plan or progress notes for the other.
Failure to document GDR for an antidepressant: A resident with major depressive disorder received DULoxetine HCl for depression and later phantom leg pain, but surveyors found no evidence of GDRs in two separate quarters with at least one month between attempts unless clinically contraindicated. An ADON said he remembered a GDR attempt but could not locate the documentation and explained that reductions would depend on the medication’s use.
Failure to Report and Investigate Allegations of Rough Care: A resident with multiple chronic conditions reported rough care during brief changes, rushed and rough bathing and incontinence care, yelling, and inappropriate comments from CNAs. Staff treated the concerns as grievances by giving a form and speaking with the CNA, but the RNC stated staff did not understand abuse reporting vs grievances, and there was no documentation that the allegations were reported to state agencies or thoroughly investigated as required by policy.
Missing transfer documentation for hospitalized residents: The facility did not document the information sent to the receiving provider for two residents transferred to the ER/hospital. One resident had asthma, pneumonia, DM2, CHF, HTN, and CKD, and the other had a femur fracture; required transfer details such as practitioner contact information, resident representative contact information, advance directive information, comprehensive care plan goals, and documentation of what records were sent were not found in the chart.
A resident with a NG tube and diagnoses including encephalopathy, AMS, DM2, and dysphagia had tube feeding bags that were inconsistently labeled with the wrong formula and rate, while the water bag was unlabeled. Staff could not verify whether Jevity 1.2 or Jevity 1.5 was infusing, and the bag labels were missing required initials and other labeling details. The RNC and RD stated the resident’s order had not changed and that Jevity 1.2 was not the correct formula.
A resident who was dependent for bathing did not receive scheduled bed baths as ordered. The resident reported going a week without a bed bath and said staff often stated they did not have enough time, while CNAs sometimes marked care as refused and attempted to have her sign refusal sheets. The record showed repeated bath refusals in the task system, only one documented bed bath in the review period, and no refusal sheets in the chart, with staff giving inconsistent accounts of the bathing refusal process.
Delayed Pain Medication Administration: A resident with chronic pain, including low back, knee, and coccyx pain, reported that scheduled Tramadol was often given late and affected pain control. The MAR showed multiple late doses outside the ordered timeframe, and staff stated the medication should be given as ordered within the allowed window, but no documentation was found for the late administrations.
Incomplete dialysis documentation was found for a resident with ESRD, DM2, and anemia in CKD. The resident’s pre- and post-dialysis forms were repeatedly left blank or only partially completed, including missing VS, access assessment, lung/GI/cardiac findings, and pain documentation. RN and ADON interviews confirmed that dialysis residents required complete pre- and post-assessments, including thrill/bruit checks, VS, dressing checks, and pain scale documentation.
A resident with renal dialysis, DM2, and anemia in CKD was ordered phosphate binders to be given with meals or before meals, but MAR review showed repeated administrations at times that did not match posted meal times. The resident stated the binder was being given before and after meals instead of with meals, and RN and ADON interviews confirmed the medication was intended to be administered with food for it to work.
Medication storage was not maintained under proper temperature controls when a medication refrigerator was found at 24 degrees Fahrenheit, below the safe range stated by staff. The refrigerator contained multiple residents’ insulin products, Trulicity, and lorazepam. RN and ADON staff both acknowledged the temperature was too low and could freeze medications, and the ADON did not verify the integrity of the medications already stored inside.
A resident with kidney failure, thrombocytopenia, and chronic myelomonocytic leukemia had a STAT EKG ordered for a low and fluctuating HR with nausea, but the EKG report was not found in the medical record. The RNC stated the facility had to call and obtain the results.
Resident information was left visible and unsecured during med pass. An RN left a report sheet with resident health information unattended on the med cart and later walked away from the cart, leaving the computer open and resident-identifiable information visible to passersby. The RN stated she should lock the computer and turn over the report sheet when leaving the cart, and the ADON stated staff should lock or close the computer and secure any personal information.
Failure to use EBP PPE during high-contact care. An RN administered meds through a resident’s NG tube without a gown, and a CNA Coordinator assisted another resident with a G-tube during repositioning and meal assistance while wearing gloves but no gown. The IP stated that EBP required gowns and gloves for residents with feeding tubes and for high-contact care activities.
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.
Failure to Provide Ordered Pressure Ulcer Interventions
Penalty
Summary
The facility did not ensure that a resident with multiple pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. The resident was admitted and later readmitted with diagnoses including stage 4 pressure ulcers of the sacral region, right buttock, left buttock, and left heel. The resident’s MDS showed the resident was unable to complete the BIMS assessment and was dependent on staff for rolling, transfers, personal hygiene, footwear, upper body dressing, and toileting hygiene. During observations from 6/22/26 through 6/24/26, the resident was repeatedly found lying on the back with the head of the bed slightly elevated, with the heels resting on top of the mattress or directly on a pillow. Multiple dry brownish-red discolorations were seen on the sheets near the resident’s feet on several occasions. The resident had bandages dated 6/21 on both heels that were peeling off the skin and sticking to the sheet or pillow. No off-loading boots or pillows were observed on 6/22/26 and 6/23/26, and the resident was not observed wearing compression socks or heel booties during that period. Physician orders included heel booties to both heels while in bed, compression stockings to both lower extremities, and instructions to maintain offloading boots in place bilaterally. The record also showed ongoing wound care for the sacral wound, including wound vac use and treatment for wound infection. However, the wound vac ordered on 5/27/26 was still not available for use as of 6/1/26, resulting in at least a 5-day delay in treatment. Staff interviews indicated the resident should have been wearing booties and compression socks, the resident was unable to reposition independently, and one RN stated she had not been trained on how to use a wound vac in the facility.
Failure to Evaluate Bedside Medication Self-Administration
Penalty
Summary
The facility did not ensure that residents who had medications in their rooms were evaluated to determine whether self-administration was clinically appropriate and safe. During observation, interview, and record review, four sampled residents were found to have medications at the bedside or in their rooms without a current self-administration evaluation or, in some cases, without a current order allowing self-administration. Facility staff confirmed that residents could not self-administer medications without both an evaluation and an order, and that these requirements were not documented for the affected residents. Resident 8 had a bottle of turmeric tablets and a white tablet on the bedside table and stated he was unsure what the white tablet was. No self-administration evaluation or order was found, and the ADON stated the resident was unable to self-administer medications. Resident 35 had prescription medication observed in the room; although a physician order documented unsupervised self-administration of triamcinolone cream, no self-administration evaluation was located, and the ADON could not find one in the record. Resident 78 had two tablets on a napkin, six tablets in a medication cup, and an inhaler on the bedside table. She was unable to state what the medications were, had a BIMS score of 12 indicating moderate cognitive impairment, and the prior order allowing bedside administration had been discontinued. No current evaluation or order was located. Resident 22 kept albuterol and Symbicort inhalers at the bedside and reported using albuterol 2 to 3 times an hour. The resident’s self-medication evaluation documented that he was not alert and oriented to person, place, and time, did not know the correct dose, and was not a candidate for self-administration. Records also documented excessive albuterol use, and staff stated the resident had short-term memory deficits and was not safe to self-administer medications. Despite this, the inhalers remained available at the bedside, and the NP stated the resident wanted the medication available without waiting for staff assistance.
Unnecessary urinary catheters and improper PureWick use
Penalty
Summary
The facility did not ensure that residents with indwelling urinary catheters were assessed for removal as soon as possible when there was no documented indication that catheterization was necessary. For 3 of 40 sampled residents, Foley catheters remained in place without an identified reason for use. The report identified residents 3, 46, and 98 as the affected residents. Resident 3 was admitted and later readmitted with diagnoses including encephalopathy, altered mental status, type 2 diabetes, and dysphagia. On observation, resident 3 had a urinary catheter hanging on the right side of the bed. Physician orders addressed catheter securement, drainage bag changes, and catheter changes, but the record did not provide documentation for why the catheter was needed. Nursing staff and the CNA stated they were unaware of the reason for the catheter, and the regional nurse consultant stated she thought it may have been related to a sacral wound but would look for documentation. The facility did not provide additional documentation supporting the indication for the catheter. Resident 98 was admitted with diagnoses including malignant neoplasm of the endometrium, secondary malignant neoplasm of bone, and pathological fracture. The resident stated she did not know why she had a urinary catheter. The record showed an admission evaluation documenting no catheter present, followed by a skilled evaluation noting a Foley catheter in place with a securement device and drainage bag. Staff interviews indicated the resident was continent, used a bedside commode, could transfer with assistance or by herself, and staff were unsure why the catheter was needed. The regional nurse consultant stated there was no diagnosis for the catheter use and that the nurse practitioner wanted to follow up with the resident before the catheter was removed. Resident 46 had diagnoses including fibromyalgia, alcoholic cirrhosis, hepatic failure, generalized anxiety disorder, major depressive disorder, and chronic pain syndrome. The resident had a PureWick device in place, and a urine collection canister was observed containing 950 milliliters of urine. The PureWick tubing was observed draped up over the head of the bed rather than positioned downward to drain by gravity, and the tubing was seen to have back-and-forth flow with suction. Staff interviews showed inconsistent understanding of how the device was being used: one CNA stated the resident directed how it should be placed and that the tubing was positioned according to the resident's preference, while an RN stated the tubing should be positioned over the leg like a down drain. The CNA coordinator stated that staff had not been trained on how to use the PureWick device before the beginning of that month and that staff were positioning it based on the resident's preference.
Missing Laboratory Reports in Resident Records
Penalty
Summary
Complete, dated laboratory records were not kept in residents’ clinical records for 3 of 40 sampled residents. For Resident 4, who was admitted with diagnoses including dependence on renal dialysis, type 2 diabetes, and anemia in chronic kidney disease, physician orders included admit labs and repeat CBCs on multiple dates, but no laboratory results could be located in the medical record. For Resident 99, who was admitted and later readmitted with diagnoses including unspecified kidney failure, thrombocytopenia, and chronic myelomonocytic leukemia, physician orders included admit labs, a CBC and BMP, and later CBC and CMP orders, but no laboratory results could be located in the medical record. For Resident 46, who was admitted with diagnoses including fibromyalgia, alcoholic cirrhosis, hepatic failure, generalized anxiety disorder, major depressive disorder, and chronic pain syndrome, multiple orders were written for LFPs, BMPs, CBC, INR/PT, prealbumin, and urinalysis with culture and sensitivity, but the laboratory results for all listed orders were not located in the medical record. The Regional Nurse Consultant stated that the lab results had to be obtained from the hospital or printed from the laboratory portal and were not contained in the residents’ medical records.
Food Storage and Cross-Contamination Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial kitchen tour, surveyors observed an opened bag of chicken breasts and a bag of raisin swirl bread in the freezer that were both undated, and an expired small carton of milk in the refrigerator with a use-by date of 5/9/26. On a later kitchen tour, surveyors again observed food in the freezer that was open to air and undated, including garlic toast in an opened box and bag, meat patties in an opened box and bag, and [NAME] fillets in an opened box and bag. Surveyors also observed problems in resident refrigerators and during meal service. In the 100 hall resident refrigerator, there was an expired yogurt container with a use-by date of 6/14/26 and four additional expired yogurt containers with a use-by date of 5/22/26. In the 300/400 hall resident refrigerator, there was an expired yogurt container with a use-by date of 6/14/26, and in the 200 hall resident freezer there were open chimichangas with no use-by date. During lunch tray line observation, kitchen staff were seen touching multiple surfaces without changing gloves, and a cook touched a hamburger bun with gloved hands and then used the same gloves to pick up gluten free bread for a gluten free resident.
Failure to Supervise Residents at Risk for Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents who were at risk for wandering or elopement. One resident with diagnoses including depression, alcohol dependence, and a history of transient ischemic attack left the facility in an Uber for a haircut and later called his daughter because he did not know how to get back. The resident had an admission BIMS score of 12 indicating moderate cognitive impairment, an admission nursing assessment documenting altered mental status and orientation only to person and place, and no current elopement assessment or care plan addressing wander or elopement risk at the time of the incident. The same resident’s record showed a prior elopement risk evaluation from a previous admission, but there was no information in the record explaining what the score meant or whether he was considered an elopement risk. After he left the facility, a nursing progress note documented that staff were notified by the daughter that he was confused and did not know how to return, and the resident was retrieved from the salon and brought back to the facility. The facility’s own investigation identified that the departure was not detected in real time because the sign-out step was not followed or verified. A second resident with diagnoses including COPD, chronic respiratory failure with hypoxia, convulsions, dementia, heart failure, and cannabis use was required to have supervised leave of absence when leaving the facility, but he left unaccompanied and was later found missing. Staff contacted police to help locate him, and he returned on his own shortly afterward stating he had gone to the gas station. His elopement risk evaluation showed a score of 12 with prior elopement or near-elopement and other behaviors placing him at risk, but there was no care plan in the record addressing his elopement risk and no nursing progress notes documenting the incident.
Failure to Document Gradual Dose Reduction for Antidepressant
Penalty
Summary
The facility did not ensure adequate monitoring of a psychotropic medication for Resident 35, who was admitted with a diagnosis including major depressive disorder. The resident had a physician order dated 9/12/25 for DULoxetine HCl 30 mg delayed release, initially 1 tablet daily for 7 days then 2 tablets daily for major depressive disorder, and that order was discontinued on 9/24/25. A subsequent physician order dated 9/24/25 continued DULoxetine HCl 30 mg, 2 tablets daily, for phantom leg pain. Survey findings stated that the resident, who was receiving an antidepressant, did not receive a gradual dose reduction in two separate quarters with at least one month between attempts unless clinically contraindicated. During an interview on 6/25/26, ADON 1 stated he remembered doing a GDR in April 2026 but could not find the documentation, and explained that if the medication was used for depression they would reduce the medication and, if the resident failed the reduction, request that the Medical Director document a contraindication.
Failure to Report and Investigate Allegations of Rough Care
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited because the facility did not have written policies and procedures in place to prohibit and prevent abuse and to investigate allegations of abuse. For Resident 46, who was admitted with diagnoses including fibromyalgia, alcoholic cirrhosis, hepatic failure, generalized anxiety disorder, major depressive disorder, and chronic pain syndrome, the survey found that staff were aware of allegations that care had been rough but did not escalate the concern up the chain of command as a possible abuse allegation. Resident 46 reported that a staff member had provided rough care during a brief change and continued despite the resident asking the staff member to stop. The resident also reported yelling, screaming, inappropriate comments, rushed bed baths, rough incontinence care, and difficulty obtaining care from certain CNAs, and stated that she stopped completing grievance forms because leadership was no longer providing resolution to her concerns. The CNA Coordinator stated that when Resident 46 reported staff being rough, she gave a grievance form and spoke with the staff member, and the RNC stated that staff were not aware of abuse reporting and the difference between abuse and a grievance. Review of the facility documentation found no evidence that the allegations of rough care were reported to state agencies or thoroughly investigated, despite the facility policy requiring immediate reporting of any suspicion of abuse and investigation of all allegations.
Missing Transfer Documentation for Hospitalized Residents
Penalty
Summary
The facility did not document in the resident medical record the information provided to the receiving provider when residents were transferred to the Emergency Room. For 2 of 40 sampled residents, the record did not show the required transfer information, including the practitioner responsible for the resident’s care, resident representative contact information, advance directive information, the comprehensive care plan, a copy of the discharge summary, and other information needed to support a safe and effective transition of care. One resident was admitted with asthma, pneumonia, type 2 diabetes mellitus, congestive heart failure, hypertension, and chronic kidney disease, and was transferred to the hospital after a bowel issue and findings of colonic ileus; the discharge transfer summary documented the reason for transfer and that the reconciled medication list was provided, but the progress notes did not document what information was sent to the receiving provider. Another resident was admitted with a fracture of the neck of the left femur and was transferred to a short-term general hospital/acute care hospital; although the discharge summary noted that the responsible party, physician, DON or designee, and administrator were notified, the discharge transfer form did not include the practitioner contact information, resident representative information and contact information, advance directive information, or comprehensive care plan goals.
Incorrectly Labeled Tube Feeding and Missing Required Labeling Information
Penalty
Summary
The facility did not ensure that tube feeding services met professional standards of quality for a resident with encephalopathy, altered mental status, type 2 diabetes, and dysphagia. The resident was admitted and later readmitted with a nasogastric tube used for tube feedings and medication administration. Physician orders in the record showed an enteral feeding order for Jevity 1.5 at 60 mL per hour continuously, along with water flush orders. During observation, the resident’s tube feeding bag was labeled with the resident’s first name and last initial, but the formula and rate were not consistently correct across observations, and the water bag was unlabeled. One observation showed the tube feed bag labeled as Jevity 1.2 at 70 mL per hour, even though the pump was running at 60 mL per hour and no physician order for Jevity 1.2 could be located in the record. Interviews confirmed the labeling and order discrepancies. RN 1 stated she had been told the tube feed order changed to Jevity 1.2, but she could not find the order, and she did not know why the bag label differed from the ordered formula. RN 1 also stated the night shift nurses changed the tube feeds and that the bag was incorrectly labeled because it did not include the nurse’s name and the water bag was not labeled. The RNC stated the resident’s order had not changed since 6/3/26 and that Jevity 1.2 was not the correct formula. The RD also stated she had not approved any recent change and that Jevity 1.2 was not correct. The facility’s tube feed policy required checking the enteral nutrition label against the order, including the resident name, formula, date and time prepared, route, access site, method, and rate, and the Lippincott procedure required labeling with patient identifiers, formula name, date and time hung, route, rate, initials of who prepared and hung it, and other required information.
Missed Scheduled Bathing Assistance
Penalty
Summary
The facility did not ensure that a resident who was dependent for bathing assistance received bathing services as scheduled. Resident 46, who was admitted with diagnoses including fibromyalgia, alcoholic cirrhosis, hepatic failure, generalized anxiety disorder, major depressive disorder, and chronic pain syndrome, was documented on the MDS as dependent for shower/bathing assistance and had a care plan noting substantial assist with bathing and a preference for bed baths. The resident stated during interview that she had not had a bed bath in a week, had only received one bed bath in the last 2 weeks, and often had to ask for hair washing and bathing assistance. She reported that staff told her they did not have enough time to complete the bath and that CNAs sometimes said she refused care and tried to have her sign a refusal sheet. Record review showed an order for bed baths on Tuesdays, Thursdays, and Saturdays, with documentation that the resident was offered baths on multiple scheduled days but that only one bed bath was documented during the 30-day review period. The bathing task record listed repeated refusals, but no shower refusal sheets were found in the medical record. Interviews with nursing staff showed inconsistent understanding of the refusal process, including whether refusal sheets were still being used and who was responsible for scanning them into the record. The regional nurse consultant stated the CNA coordinator reported that shower sheets had been discontinued a few months earlier and that the new process was to document bathing in the tasks, but she was not sure the process change had been implemented.
Delayed Pain Medication Administration
Penalty
Summary
Safe, appropriate pain management was not provided for a resident who required it. Resident 54 was admitted and later readmitted with diagnoses including asthma, pneumonia, type 2 diabetes mellitus, congestive heart failure, hypertension, chronic kidney disease, and low back pain. During interview, the resident stated he had lower back pain, bilateral knee pain, and coccyx pain related to a pressure ulcer, and that he took Tramadol and Tylenol for pain. He reported that his Tramadol dose was frequently administered late and that this affected his pain control. The resident had a physician order for Tramadol 50 mg tablets given in scheduled doses at 8:00 AM, 12:00 PM, and 8:00 PM. The June 2026 MAR showed multiple administrations more than one hour after the scheduled time, including on 6/1, 6/3, 6/8, 6/11, 6/20, and 6/22. RN 6 stated the medication could be given one hour before or after the scheduled time, and ADON 1 stated medications should be administered as ordered within that timeframe. ADON 1 also stated the resident slept a lot and that late administration should be documented and the provider notified if the medication was not given as ordered, but no documentation was found for the late Tramadol administrations.
Incomplete Dialysis Assessment Documentation
Penalty
Summary
Incomplete dialysis communication and assessment documentation was identified for Resident 4, who was admitted with diagnoses including dependence on renal dialysis, type 2 diabetes, and anemia in chronic kidney disease. Physician orders required staff to complete the Dialysis Post Assessment Form after the resident returned from dialysis, ensure the Pre-Dialysis Assessment and Communication Form was completed and sent with the resident, and review and follow up as indicated. The facility’s pre- and post-dialysis assessment forms were reviewed and showed multiple missing entries for this resident. The post-dialysis assessment was blank on 5/20/26, 5/29/26, 5/31/26, and 6/22/26. The pre-dialysis assessment on 6/3/26 did not document vital signs, and the pre-dialysis assessment on 6/12/26 did not document the type of dialysis access, lung assessment, gastrointestinal and cardiac systems, or pain level; the post-dialysis assessment for that date only documented that the resident had dialysis, with the remainder of the form blank. RN 5 stated that dialysis residents required pre- and post-evaluations, including checking for thrill and bruit, vital signs, dressing check, and pain scale. ADON 1 stated that nursing staff were expected to complete the pre- and post-evaluation forms and that the forms should be filled out in their entirety.
Phosphate Binder Not Given With Meals
Penalty
Summary
Resident 4, who was admitted with diagnoses including dependence on renal dialysis, type 2 diabetes, and anemia in chronic kidney disease, was ordered phosphate binders including sucroferric oxyhydroxide and later Renvela (sevelamer carbonate). The physician orders specified that the medication was to be given with meals or before meals for phosphorus binding. Resident 4 stated during interview that she had been receiving the phosphate binder before and after meals rather than with meals, and that the medication needed to bind the phosphates in her food so her body did not absorb them. She also stated that she ate her meals in her room. Review of the MAR showed multiple administrations of the phosphate binder at times that did not align with the facility’s posted meal times for the 200 hall. Breakfast, lunch, and dinner were posted as 8:10 AM, 12:40 PM, and 5:55 PM, respectively, while the medication was frequently given well before or after those times, including early morning doses and doses administered hours after meals. RN 5 stated that Renvela was a binder that was supposed to be given with meals and that she would wait until the resident received the meal tray before administering it. ADON 1 stated that Renvela needed to be taken with food, that it binded with phosphate in food, and that the medication should be adjusted to when the resident received meals.
Medication Refrigerator Stored at Improper Temperature
Penalty
Summary
Drugs and biologicals were not stored under proper temperature controls when the medication refrigerator on the 300/400 hallway was observed with an internal temperature of 24 degrees Fahrenheit. During the observation, RN 3 stated the temperature was not in the safe zone, which was between 34 and 40 degrees, and said that at 24 degrees the medications risked freezing. The refrigerator contained multiple residents’ medications, including Resident 5’s insulin lispro pens and vials, Resident 73’s Admelog Solostar pens and insulin lispro pen, Resident 46’s Trulicity pen, and Resident 41’s lorazepam liquid. During interview, ADON 1 stated the medication refrigerator temperatures should be within 36 to 46 degrees Fahrenheit and acknowledged that a temperature of 24 degrees could cause medications to freeze. ADON 1 stated the medications would be moved to another refrigerator until the temperature could be verified, but did not seek to verify the integrity of the medications already stored in the refrigerator. The facility policy for Medication Labeling and Storage stated that drugs and biologicals were to be stored in locked compartments under proper temperature, humidity, and light controls, but it did not specify the proper refrigerator temperature.
Missing EKG Report in Resident Record
Penalty
Summary
The facility failed to keep signed and dated reports of diagnostic services in the resident record. For Resident 99, who was admitted and later readmitted with diagnoses including unspecified kidney failure, thrombocytopenia, and chronic myelomonocytic leukemia, a STAT EKG was ordered on 6/1/26 due to a heart rate ranging from 37 to 54 and nausea. During record review, the EKG report was not located in the resident's medical record. In an interview on 6/24/26, the Regional Nurse Consultant stated the EKG was not in the resident's medical record and that the facility had to call and obtain the results.
Resident Information Left Visible and Unsecured
Penalty
Summary
The facility did not keep resident medical record information confidential or safeguard it from unauthorized access. During morning medication administration on 6/24/26, RN 8 was observed leaving her report sheet unattended and visible on the medication cart outside a resident room, with a resident roster containing health information visible to passersby. Later that morning, RN 8 walked away from the medication cart to obtain additional medication and left her nurse report sheet and computer unattended, with resident-identifiable health information still visible to passersby. When interviewed immediately after returning to the cart, RN 8 stated she should lock the computer and turn over her nurse report sheet when walking away. ADON 1 later stated that staff should lock the computer screen or close the lid so no resident-identifiable information is visible and that anything with personal information should be covered or secured.
Failure to Use EBP PPE During High-Contact Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment. For Resident 3, who was admitted and readmitted with diagnoses including encephalopathy, altered mental status, type 2 diabetes, and dysphagia oropharyngeal phase, an RN was observed administering medications through the resident’s nasogastric tube without wearing a gown. During interview, the RN stated that Enhanced Barrier Precautions (EBP) included gloves and a gown, that EBP was used for residents with urinary catheters, feeding tubes, or wounds, and that a gown and gloves were to be worn when administering medications through a tube feed. The Infection Preventionist also stated that EBP was required for residents with urinary catheters, feeding tubes, and wounds, and that administering medications through a feeding tube required a gown and gloves. For Resident 15, who had diagnoses including nontraumatic intracranial hemorrhage, dysarthria, and encounter for gastrostomy tube, the resident had a physician order for EBP due to a feeding tube. During observation, gowns and gloves were present in the room near the door, and the resident confirmed having a feeding tube in the stomach. A CNA Coordinator assisted the resident with repositioning and dining assistance, including reaching under the resident’s bilateral arms and pulling the resident up in the chair, with direct contact to the resident and the wheelchair, while wearing gloves but not a gown. The Infection Preventionist stated that EBP was initiated for residents with urinary catheters, intravenous access, wounds, or tube feeds, and that staff should wear a gown and gloves for high contact care activities, including repositioning when making direct contact with the resident or immediate environment.
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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