Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Taylorsville during CMS and state inspections, most recent first.
A resident with cervical spinal cord injuries, cognitive communication deficit, spastic hemiplegia, and intermittent confusion sustained a second-degree burn during heat therapy. The RNA used hot water and towels without checking the temperature with a thermometer, and the resident later had blistering and skin peeling to the left forearm and hand. The ED documented the injury as a burn, and the restorative nursing record did not include heat therapy recommendations.
An LPN left a resident’s simvastatin blister pack unattended on top of the med cart while administering meds, and surveyors found an open vial of Lantus insulin for one resident past its usable date plus an open Tuberculin vial with no open date documented. The UM and DON acknowledged the labeling and storage issues, including that the insulin should have been discarded and the Tuberculin vial should have had an open date recorded.
Surveyors found that residents’ personal food was not stored according to posted standards when two containers in a designated personal food refrigerator—one with a cloudy brown soup-like liquid and meat-like substance, and another with vegetables—were observed without any resident name or date labels, despite a sign requiring all items to be labeled and discarded after three days. An LPN acknowledged the items should be thrown away due to missing labels, and the DON stated she was responsible for checking the fridge and that food was supposed to be discarded after three days.
Failure to Notify Resident of Charges to Personal Funds: A resident with MS, functional quadriplegia, DM2, epilepsy, MDD, anxiety, and cognitive communication deficit had supplemental dental and vision insurance premiums taken from personal funds without advance notice or documented authorization from the resident or POA. Interviews with the POA, BOM, and ARD showed the facility used the resident’s account balance to pay overdue premiums instead of the intended cost-of-care deductions, and the resident was not informed of the financial changes.
Failure to provide quarterly financial statements for a resident’s deposited personal funds. A resident with MS, functional quadriplegia, DM2, epilepsy, MDD, anxiety, and cognitive communication deficit had a POA who reported asking the BOM for an account record without response. The BOM was unsure the quarterly statement was being provided, and the ARD stated statements were mailed without documentation, then said they were delivered to the resident’s room and shredded; the ARD also questioned whether the resident had a POA.
A resident with multiple chronic diagnoses had Medicaid-related supplemental dental and vision premiums deducted from personal funds instead of being handled through the facility’s COC arrangement. Financial records showed repeated premium withdrawals, an additional unexplained deduction, and an overdeduction of COC, while the BOM, ARD, and POA stated the premiums were supposed to be paid by the facility and not charged to the resident’s account.
Failure to notify a resident of Medicaid coverage changes. A resident with MS, functional quadriplegia, DM2, epilepsy, MDD, anxiety, and cognitive communication deficit had Medicaid-funded supplemental dental and vision insurance changed without timely notice to the resident. The POA said the resident had minimal monthly income and a zero account balance, while the BOM said notice was sent to the POA and the ARD stated they were not notified by Medicaid and did not need to notify the resident because they were the rep payee.
Inappropriate AMA Discharges After LOA: Two residents were discharged after leaving the facility on LOA, but the records did not show a clear, documented basis for the AMA discharges. One resident was cognitively intact with multiple chronic diagnoses and was documented as alert and oriented, yet staff gave conflicting accounts about supervision, IV access, and whether an AMA form was signed. The other resident had moderate cognitive impairment and a rib fracture, and the chart contained inconsistent documentation about the LOA, missing AMA paperwork, and unclear discharge planning details.
Failure to Provide Scheduled Showers: A resident with CVA, bacterial meningoencephalitis, nontraumatic intracranial hemorrhage, ataxia, dysphagia, and cognitive communication deficits did not receive showers as scheduled. The resident stated she had only two showers since admission and wanted more. Records showed she required substantial/maximal to dependent assistance for bathing, had no documented refusals, and did not receive the showers listed on the shower schedule. CNA and DON interviews confirmed the resident did not receive two showers per week as scheduled.
Incomplete Pre- and Post-Dialysis Assessments: A resident with ESRD, cardiomyopathy, and an automatic cardiac defibrillator was ordered to receive dialysis three times weekly, but required pre- and post-dialysis assessments were not consistently documented. Review showed 15 of 44 dialysis opportunities lacked the assessment forms in the EMR, despite staff stating that pre-dialysis checks should include fistula and BP assessment and post-dialysis checks should include vital signs, fistula assessment, and monitoring for bleeding.
Pharmacy Medications Not Available for Ordered Treatment: Two residents missed ordered medications because they were not available from the pharmacy. One resident with DM missed seven doses of dapagliflozin propanediol, and another resident with a broken tooth and an order for Peridex mouthwash missed the first seven doses. An LPN said the facility had pharmacy issues, and the DON said there were communication problems and providers were aware.
Blood pressure medications were administered outside ordered parameters and professional standards for a resident with heart failure, ESRD, pulmonary HTN, and ventricular tachycardia. MAR review showed Midodrine was given when BP was at or above the hold parameter, Metoprolol was given when systolic BP was below 100, including one dose at 87/42, and both medications were given at the same time multiple times. An LPN and the DON stated Metoprolol and Midodrine should have been held under certain BP conditions and should not have been administered together.
A resident reported breaking a tooth at the facility and said the pain was intermittent, staff had not offered pain meds, and she had been told she would see a dentist but had not. Record review and staff interviews showed the LPN and NP were aware of the broken tooth and ordered Peridex, but the resident was not yet scheduled for dental care and the RRM was not aware of the need until later. The facility policy stated routine and emergency dental services are available through a contract dentist, the resident’s personal dentist, community dentists, or other health care organizations.
Missed Urology Referral for Resident With Catheter Leaking: A resident with muscle weakness, catheter use, and neurogenic bladder had a physician order for a urology referral for a suprapubic eval related to frequent catheter leaking, but the referral was not made for an extended period. The DON was unsure why it was missed, the RRM said no appointment was on the calendar and that nursing handles appointments, and a UM stated the first referral was missed.
Inadequate Supervision During Heat Therapy Resulted in a Burn
Penalty
Summary
The facility failed to ensure that each resident received adequate supervision to prevent accidents when Resident 76 sustained a second-degree burn during heat therapy. Resident 76 was admitted and readmitted with diagnoses including anterior cord syndrome at C3 level of the cervical spinal cord, completed lesions at C4, C5, and C6, cognitive communication deficit, spastic hemiplegia, and paresthesia of the skin. On 2/2/26, the resident reported that hot water in the shower burned his arm, and he was observed with a wrap on the left forearm and two blisters on knuckles of the left hand. Record review showed the resident was sent to the hospital after staff found a rash with skin peeling to the left arm and large blisters on the left hand. The emergency department documented findings consistent with a second-degree burn isolated to the left forearm, with blistering on the left hand digits, and stated it appeared to be a burn rather than a medication reaction. The RNA stated he provided heat therapy using hot water and towels, did not test the water temperature with a thermometer that day, and placed hot wet towels on the resident's left forearm and hand. The DOR stated the facility did not have a hydrocollator, that warmed towels could not be heat regulated to prevent burns, and that Resident 76 had intermittent confusion. The restorative nursing program document did not include heat therapy recommendations, and the DON stated she thought there was a recommendation to provide heat therapy.
Unsecured and Improperly Labeled Medications
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles. During morning medication administration, an LPN left a blister pack of simvastatin for resident 70 on top of the medication cart outside the resident’s room and walked away from the cart without securing the medication inside the locked cart. The LPN stated it was easier to pull all the blister packs out of the cart while dispensing medication and that she forgot to put the simvastatin back inside the cart before walking away. Additional observations found an open multidose vial of Lantus insulin for resident 7 on the hallway medication cart with an open date of 12/25/25, and the UM stated the vial was good for 28 days past the open date and should be discarded. An open multidose Tuberculin vial was also found in the medication fridge with no open date documented on the vial or box. The UM stated the open date should have been documented, and the DON stated nursing staff should write the open date on the vial and box, that the insulin was past the expiration date and should have been discarded, and that if staff could not determine the open date they should discard the medication.
Failure to Label and Date Residents’ Personal Food Items in Refrigerator
Penalty
Summary
The facility failed to store residents’ personal food in accordance with its own posted standards and professional food service safety practices. During observation of the resident personal food refrigerator, surveyors noted a sign instructing that all items must be labeled with the resident’s name and date, must be covered, and would be discarded after three days. Inside the refrigerator, there was a large container holding a cloudy, brown, soup-like liquid with a brown meat-like substance, and a separate styrofoam container containing vegetables; neither container was labeled with a resident name or date. An LPN confirmed that the unlabeled food items should be discarded because they were not labeled as required. The DON reported that she was responsible for checking the fridge for expired or undated food and discarding such items, and stated that food was supposed to be thrown away after three days in the fridge. No specific resident medical histories or conditions were described in relation to this deficiency, and the report focused solely on the improper storage and labeling of personal food items in the resident refrigerator.
Failure to Notify Resident of Charges to Personal Funds
Penalty
Summary
The facility did not ensure that a resident had the right to manage financial affairs and to know in advance what charges would be taken from personal funds. Resident 54 was admitted and later re-admitted with diagnoses including multiple sclerosis, functional quadriplegia, type 2 diabetes mellitus, epilepsy, major depressive disorder, anxiety disorder, and cognitive communication deficit. The resident’s profile listed the POA as the responsible party for care and financial matters, although it also indicated the resident was their own responsible party. The record showed that on 8/15/23 the POA completed an application for supplemental dental and vision insurance with monthly premiums totaling $218.00, and the application indicated the bill should be sent to the facility. The resident’s financial statement documented insurance premium deductions totaling $2,280.00 from the personal funds account from May 2025 through December 2025. Interviews with the POA, BOM, ARD, and resident’s record review showed the facility did not deduct the premiums from the facility’s cost of care amount as intended. Instead, the facility used the resident’s remaining account balance and personal funds to pay the overdue premiums and back payment without documentation showing the resident or POA authorized that use of funds. The ARD stated the facility was the resident’s rep payee and therefore decided to deduct the back payment from the resident’s account balance, and later confirmed the resident was not given the opportunity to be informed of the changes made to the financial account.
Failure to Provide Quarterly Financial Statements
Penalty
Summary
The facility did not ensure that the financial record for a resident whose personal money was deposited with the nursing home was available to the resident through quarterly statements and upon request. Resident 54 was admitted and later re-admitted with diagnoses including multiple sclerosis, functional quadriplegia, type 2 diabetes mellitus, epilepsy, major depressive disorder, anxiety disorder, and cognitive communication deficit. The resident’s profile listed a POA as the responsible party for care and financial matters, while also indicating the resident was their own responsible party. During interview, the resident’s POA stated that the resident received $42.00 per month from Social Security, that the current account balance was zero, and that she had asked the BOM for a record of the prior year’s account but had not received a response. The BOM stated that the POA should receive a quarterly statement but she did not think it was done. The ARD stated that statements were mailed quarterly to the POA but there was no documentation to verify they were sent, then stated the quarterly statements were delivered to the resident’s room and shredded because staff did not want to leave the documentation behind for anyone to see. The ARD also stated the statement would not be mailed to the POA because they were the resident’s representative payee, then asked whether the resident had a POA.
Improper Deduction of Medicaid-Related Insurance Premiums from Resident Funds
Penalty
Summary
Charges were imposed against a resident’s personal funds for items that were documented as being paid under Medicaid, specifically supplemental dental and vision insurance premiums. The resident was admitted with multiple chronic conditions including multiple sclerosis, functional quadriplegia, type 2 diabetes mellitus, epilepsy, major depressive disorder, anxiety disorder, and cognitive communication deficit. The resident’s record showed a Medicaid cost of care (COC) amount that was to be paid to the facility, and the supplemental insurance application indicated the monthly premiums were to be billed to the facility. The resident’s financial records showed repeated deductions from the resident’s personal funds account for insurance premiums, including multiple monthly premium withdrawals and an additional unexplained deduction. The facility also deducted an amount for COC that exceeded the documented COC amount. After these deductions, the resident’s account balance was reduced to a small remaining amount. The record review documented that the insurance premium deductions totaled $2,280.00 from the resident’s personal funds account, and the additional unexplained deduction brought the total deductions other than COC to $2,527.70. Interviews with the BOM, ARD, and the resident’s POA showed that the facility knew the supplemental dental and vision insurance was a Medicaid-related program and that the premiums were supposed to be handled through the facility’s COC arrangement, not from the resident’s personal funds. The BOM and ARD stated that the facility used the resident’s remaining account balance to pay overdue insurance premiums and back payments, and the ARD stated there was no documentation authorizing the facility to use the resident’s personal funds for those payments. The POA stated she was told the policy would be paid by the facility and would not affect the resident’s Social Security or Medicaid, and she later learned the facility had been making the payments from the resident’s account.
Failure to Notify Resident of Medicaid Coverage Changes
Penalty
Summary
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Based on interview and record review, the facility did not inform Medicaid-eligible residents when changes were made to items and services provided. For Resident 54, who was admitted and re-admitted with diagnoses including multiple sclerosis, functional quadriplegia, type 2 diabetes mellitus, epilepsy, major depressive disorder, anxiety disorder, and cognitive communication deficit, the facility changed the resident’s Medicaid-funded supplemental vision and dental insurance without providing timely notice to the resident of those changes. Resident 54’s medical record identified the POA as the responsible party for care and financial matters, while also indicating the resident was their own responsible party. During interview, the POA stated the resident received $42.00 per month from Social Security and had a zero account balance, and said she had requested a record of the prior year’s account from the BOM but had not received a response. The BOM stated Medicaid had taken Resident 54 off the supplemental dental and vision insurance and that notice of this decision was sent to the POA. The ARD stated they were not notified by Medicaid that the insurance was no longer covered and said they should have been informed, but they never received the notice; the ARD also stated that because they were the resident’s representative payee, they did not need to notify the resident of the cost of services or any changes made.
Inappropriate AMA Discharges After Leave of Absence
Penalty
Summary
The facility inappropriately discharged two residents after they went on leave of absence, despite the records showing that the discharges were not based on a documented resident request, a completed discharge process, or a clearly documented clinical determination that the residents no longer needed facility services. For Resident 115, the record showed diagnoses including congestive heart failure, respiratory failure, muscle weakness, Crohn's disease, type II diabetes, and COPD. He was cognitively intact with a BIMS score of 15 out of 15 and was documented as alert and oriented with minimal assistance needs for mobility on a safety evaluation. The record also showed that he signed the LOA sign-out book, but the LOA paperwork did not indicate that he required supervision. Resident 115 left the facility and later returned with his partner. Staff documented that he had left without following the LOA process and was considered AMA. Notes reflected that he was told he had to leave because he had previously left AMA, and police were called to ensure he left the premises. The provider discharge evaluation did not document the rationale for the AMA discharge. Facility staff gave conflicting accounts about whether he had been supervised, whether he had IV access, and whether he had signed an AMA form. The facility was unable to provide a LOA policy when requested. For Resident 137, the record showed a diagnosis of a left rib fracture and a BIMS score of 8 out of 15, indicating moderate cognitive impairment. Documentation stated that he went on LOA and never returned, and the facility later recorded him as discharged AMA. The record also included discharge planning notes stating that he expected to be discharged to the community, with barriers including being unhoused, and that discharge was planned in the next week. Staff interviews showed inconsistent accounts about whether he signed out, whether he returned, whether he was mentally stable, and whether the facility had a defined time frame for LOA. The AMA paperwork could not be located in the medical record, and the documentation did not show a clear, consistent discharge process before he was marked discharged.
Failure to Provide Scheduled Showers
Penalty
Summary
Resident 116 was not provided the showers scheduled in the facility bathing task and shower schedule. The resident was admitted with diagnoses including cerebral infarction, bacterial meningoencephalitis, nontraumatic intracranial hemorrhage, ataxia, dysphagia, and cognitive communication deficits. On interview, the resident stated she had only two showers since admission and wanted more. The bathing task documented that she was scheduled for showers on Wednesday and Saturday during the day shift, and the task showed she required substantial/maximal assistance to dependent assistance for bathing. Record review showed the resident received a shower or bed bath on 1/7/26, 1/12/26, 1/19/26, and 1/28/26, with no documented refusals. The shower schedule indicated she should also have received showers on 12/24/25, 12/26/25, 12/31/25, 1/3/26, 1/10/26, 1/14/26, 1/17/26, 1/21/26, and 1/24/26. CNA 1 stated the resident's shower schedule was a morning shower on Wednesday and Saturday and that showers were documented on a skin observation shower form and then in the electronic medical record. The DON stated residents were provided showers two days a week per the shower schedule and confirmed the resident did not receive two showers per week as scheduled.
Incomplete Pre- and Post-Dialysis Assessments
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for Resident 13, who was admitted with diagnoses including end stage renal disease, automatic cardiac defibrillator, cardiomyopathies, and hypo-osmolality and hyponatremia. A physician order dated 8/25/25 directed staff to complete the Dialysis Post Assessment Form after the resident returned from dialysis, ensure the resident returned with the Pre-Dialysis Assessment and Communication Form, and review and follow up as indicated. Another order dated 8/22/25 indicated the resident was to receive dialysis on Mondays, Wednesdays, and Fridays at 8:00 AM. Review of pre- and post-dialysis assessments from 12/10/25 through 1/28/26 showed that, out of 44 opportunities, 15 pre and/or post dialysis assessments were not in the medical record. During interview, an LPN stated that before dialysis the nurse should check the fistula site and blood pressure, and after dialysis should obtain vital signs, check the fistula for bruit and thrill, assess for swelling or redness, and monitor for bleeding. The DON stated that a pre and post dialysis assessment should be completed in the EMR each time a resident had dialysis.
Pharmacy Medications Not Available for Ordered Treatment
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not ensure routine and emergency drugs and biologicals were available from the pharmacy for administration. For 2 of 41 sampled residents, medications ordered by the provider were not available, resulting in missed doses. Resident 2, who had diagnoses including type 2 diabetes mellitus, had a physician order dated 1/3/26 for Dapagliflozin Propanediol 5 mg by mouth daily for DM, and the January 2026 MAR showed seven missed doses because the medication was not available from the pharmacy. Resident 49, who had diagnoses including diverticulitis of the large intestine without perforation or abscess without bleeding, reported on 1/27/26 that she had broken a tooth about a week earlier, had pain that could be "a little stabby," had not been offered pain medications, and felt staff had forgotten about her. A physician communication note dated 1/23/26 documented an order for Peridex mouthwash twice daily, with the patient notified and agreeing. The January 2026 MAR showed the first seven doses were missed because Peridex was not available from the pharmacy. An LPN stated the facility had issues with the pharmacy and was switching pharmacies in March, and that the NP ordered Peridex to prevent the tooth from getting infected. The DON stated there were issues with communication, the pharmacy had been trying to do better, and providers were aware.
Blood Pressure Medications Given Outside Ordered Parameters
Penalty
Summary
The facility did not ensure that each resident’s drug regimen was free from unnecessary drugs when blood pressure medications were administered outside of ordered parameters and professional standards of care. Resident 13 was admitted with diagnoses including heart failure, end stage renal disease, an automatic cardiac defibrillator, pulmonary hypertension, and ventricular tachycardia. The resident had orders for Metoprolol Succinate ER 12.5 mg daily for hypertension and Midodrine 5 mg twice daily for hypotension, with Midodrine to be held if blood pressure was 110/60 or higher. Review of the December 2025 and January 2026 MARs showed Midodrine was given when blood pressure was 110/60 or higher on two occasions, Metoprolol Succinate was given when systolic blood pressure was below 100 on 11 occasions, including one administration when the documented blood pressure was 87/42, and both Midodrine and Metoprolol Succinate were administered at the same time 17 times. During interviews, an LPN stated Metoprolol should be held if systolic blood pressure was under 110 and Midodrine should be held if systolic blood pressure was over 110, and that the two medications should not be given at the same time. The DON stated Metoprolol should have been held if systolic blood pressure was less than 100, the nurse should have used clinical judgment and contacted the provider if concerned, Midodrine should have been held according to the ordered parameters, and Midodrine and Metoprolol should not have been administered at the same time.
Failure to Arrange Dental Care for Resident With Broken Tooth
Penalty
Summary
The facility failed to provide or obtain outside resources for routine and 24-hour emergency dental services for a resident who reported a broken tooth. Resident 49, admitted with diagnoses including diverticulitis of the large intestine without perforation or abscess without bleeding, told the surveyor on 1/27/26 that she broke a tooth about a week earlier at the facility, that the pain could be “a little stabby,” that staff had not offered pain medication, and that she felt staff had forgotten about her. She also stated staff told her she would see a dentist, but that had not happened. Record review showed a communication note on 1/23/26 documenting that Peridex mouthwash was ordered twice daily and that the patient was notified and agreed. On 1/29/26, an LPN stated she and the NP had been in the resident’s room addressing left arm swelling when the resident mentioned the broken tooth, and that they were working on getting her seen by the dentist. The LPN stated Social Services would coordinate the dentist and place the resident on the list, and that the NP ordered Peridex to prevent infection until the resident could be seen. The Resident Relations Manager stated she was not aware the resident needed dental care, would add her to the list, and would make a referral to the dentist. The facility policy stated routine and emergency dental services are available through a contract dentist, the resident’s personal dentist, community dentists, or other health care organizations, and that social services representatives assist with appointments and transportation.
Missed Urology Referral for Resident With Catheter Leaking
Penalty
Summary
The facility failed to obtain outside professional resources to provide a required service when a urology referral was not made for Resident 70. The resident was admitted with diagnoses including muscle weakness, need for personal assistance, catheter use, and neurogenic bladder. A physician order dated 11/17/25 directed staff to refer the resident to urology for a suprapubic evaluation related to frequent catheter leaking, but no referral was made until 1/13/26. During interviews on 2/3/26, the DON stated she was unsure why the referral had not been made, the RRM stated there was no appointment for the resident on the calendar and that nursing makes those appointments while she only arranges transportation, and UM 2 stated the first referral was missed and that a new system for making appointments and following up had started the prior week.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Salt Lake City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cascades At Riverwalk | 1.4 mi | ★★★★★ | 20 | 0 |
| Legacy Village Rehabilitation | 1.9 mi | ★★★★★ | 2 | 0 |
| Aspen Ridge West Transitional Rehab | 2.6 mi | ★★★★★ | 11 | 0 |
| Aspen Ridge Transitional Rehab | 3.7 mi | ★★★★★ | 1 | 0 |
| Rocky Mountain Care - Cottage On Vine | 3.7 mi | ★★★★★ | 1 | 0 |
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