Monument Healthcare Pioneer Trail

Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there was expired food in the dairy refrigerator, expired food in the main refrigerator, expired food in the resident refrigerator, unlabeled and undated food in the resident refrigerator, and the facility dish machine was not testing at the required levels. Findings included: On 3/31/25 at 8:05 AM, an initial tour of the kitchen was completed. The following observations were made: a. There was an opened bag of whipped topping with no visible opened date. b There was an open container of parmesan cheese with a use by date of 3/20/25. c. There was an opened container of mozzarella cheese with a use by date of 3/11/25. d. There was a box of lemons with a received date of 1/24/25. e. There was a box of butterscotch cookie drops open to air and discolored with an opened date of 7/23/24. On 3/31/25 at 10:01 AM, an initial inspection of the resident refrigerator was completed. The following observations were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, for 2 out of 27 sampled residents, notification to the SSA and APS was not done when a resident with cognitive impairments punched another resident in the back. Resident identifiers: 20 and 36. Findings included: 1. Resident 36 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, chronic post-traumatic stress disorder (PTSD), and major depressive disorder. Resident 36's medical was reviewed on 4/1/25 through 4/3/25. An admission Minimum Data Set assessment dated [DATE], documented that resident 36 had a Brief Interview for Mental Status (BIMS) score of 99. A BIMS score of 99 indicated that the interview was not completed. On 2/5/25 at 1:20 AM, a Nursing Note documented Note…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility in response to allegations of abuse did not have evidence that all alleged violations were thoroughly investigated. Specifically, for 2 out of 27 sampled residents, a resident to resident allegation of abuse was not investigated. Resident identifiers: 20 and 36. Findings included: 1. Resident 36 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, chronic post-traumatic stress disorder (PTSD), and major depressive disorder. Resident 36's medical was reviewed on 4/1/25 through 4/3/25. An admission Minimum Data Set assessment dated [DATE], documented that resident 36 had a Brief Interview for Mental Status (BIMS) score of 99. A BIMS score of 99 indicated that the interview was not completed. On 2/5/25 at 1:20 AM, a Nursing Note documented 'Note Text: Nurse heard banging coming from his room and headed to the room to check it out. room [ROOM NUMBER]A came out of his room and called the nurse. Nurse went…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Specifically, for 1 out of 27 sampled residents, a resident that was a fall risk on admission did not have a baseline care plan developed within 48 hours of the resident's admission. Resident identifier: 36. Findings included: Resident 36 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, chronic post-traumatic stress disorder, and major depressive disorder. Resident 36's medical was reviewed on 4/1/25 through 4/3/25. On 1/13/25 at 5:20 PM, a Morse Fall Scale Evaluation documented that resident 36 was a High Risk for Falling with a score of 50. An admission Minimum Data Set assessment dated [DATE], documented that resident 36 had a Brief Interview for Mental Status (BIMS) score of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not keep the resident environment as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 2 out of 27 sampled residents, a resident was observed to have medication left at bedside and a resident that was a high risk for falls did not have interventions in place prior to the resident having a fall. Resident identifiers: 20 and 36. Findings included: 1. Resident 20 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, chronic obstructive pulmonary disease, nonpyogenic thrombosis of intracranial venous system, edema, and chronic pain syndrome. On 4/1/25 at 3:32 PM, an observation and interview were conducted with resident 20. There was an orange tablet inside a medication cup on resident 20's bedside table. Resident 20 stated that the tablet was his buprenorphine medication which he took for pain. Resident 20…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents who used psychotropic drugs received gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, for 1 out of 27 sampled residents, the provider failed to implement a GDR for a resident who had been receiving an antidepressant medication for depression since April 2024. There was no documentation stating that a GDR would be clinically contraindicated. Resident identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, progressive supranuclear ophthalmoplegia, myoneural disorder, type 2 diabetes, hypertensive heart disease with heart failure, and depression. Resident 9's medical record was reviewed on 3/31/25 through 4/3/25. On 4/2/24, a physician's order documented Escitalopram Oxalate Tablet 10 MG [milligrams] Give 1 tablet by mouth one time a day related to DEPRESSION. There had been no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, for 1 out of 27 sampled residents, a resident was given an oral antibiotic that was resistant to treat her urinary tract infection (UTI) and then required intravenous (IV) antibiotics. Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included obstructive and reflex uropathy, type 2 diabetes mellitus, and dementia. On 4/1/25 at 8:23 AM, an interview was attempted with resident 15. Resident 15 was unable to answer any questions. Resident 15's medical record was reviewed. A quarterly Minimum Data Set assessment dated [DATE], documented that resident 15 had a Brief Interview for Mental Status (BIMS) score of 15. A BIMS score of 13 to 15 indicated intact cognitive function. On 3/6/25 at 3:37 PM, a nurse practitioner…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record reviews, interviews, and facility document and policy review, the facility failed to report allegations of abuse within the required two-hour timeframe. This failure affected 4 of 5 total allegations of abuse reviewed by the survey team, involving 5 (Residents #4, #189, #15, #19, and #16) of 6 sampled residents reviewed for abuse concerns. On 10/22/2022 and 12/26/2022, facility staff observed Resident #189 touch Resident #4 inappropriately. The facility did not report either allegation of sexual abuse to the state survey agency. On 03/16/2023, Resident #15 alleged Resident #4 hit them, but the facility did not report the allegation of physical abuse to the state survey agency until 03/19/2023 after a second allegation was made. On 04/27/2023, Resident #19 alleged that Resident #16 inappropriately touched them, and the facility did not report the allegation of sexual abuse to the state survey agency until 04/28/2023. Findings included: A review of a facility policy titled, Freedom from Abuse, Neglect and Exploitation, dated 11/2017, revealed, 3. When the facility has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and facility document and policy review, the facility failed to protect the resident's right to obtain copies of the resident's medical record upon request for 1 (Resident #37) of 1 sampled discharged resident. Findings included: A review of a facility policy titled, Resident Records- Identifiable Information, revised 05/04/2023, indicated, 5. Medical records will be kept confidential, except when release is: a. To the individual or their representative where permitted by applicable law. A review of Resident #37's admission Record indicated the facility admitted the resident on 05/20/2023 with diagnoses including the presence of a left artificial knee joint, major depression, and anxiety disorder. The record indicated the resident was discharged from the facility on 06/06/2023 to a private home with home health services. The 5-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/25/2023, revealed Resident #37 had a Brief Interview for Mental Status (BIMS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review, and facility policy and document review, the facility failed to follow and implement their abuse policies by failing to protect a resident from further potential abuse for 1 (Resident #4) of 7 residents reviewed for abuse prohibition. Specifically, Resident #4 was sexually abused by Resident #189 on 10/23/2022. Resident #189 continued having sexually inappropriate behaviors and then Resident #4 was sexually abused by Resident #189 again on 12/26/2022. During the incident on 12/26/2022, a staff member left the residents alone to get help while Resident #189 was still abusing Resident #4. Findings included: A review of a facility policy titled, Freedom from Abuse, Neglect and Exploitation, dated November 2017 and last revised 09/13/2022, revealed, The facility will provide a safe resident environment and protect residents from abuse. The facility will keep residents free from abuse, neglect, misappropriation of resident property, and exploitation. This includes freedom from verbal, mental, sexual, or physical abuse, corporal punishment, involuntary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review, and facility document and policy review, the facility failed to develop and implement a care plan with appropriate interventions to prevent resident-to-resident sexual abuse. Specifically, Resident #189 began having increased sexual behaviors toward staff and residents on approximately 10/11/2022. On 10/23/2022, Resident #189 touched Resident #4 inappropriately on the breast and on 12/26/2022 a second incident occurred where Resident #189 and Resident #4 were left unsupervised and Resident #189 touched Resident #4 on the legs, private area, and breast area. The facility did not implement Resident #189's care plan that directed staff to redirect the resident away from female residents. Findings included: The facility policy titled, Freedom from Abuse, Neglect and Exploitation dated November 2017 and last revised 09/13/2022, revealed, The facility will provide a safe resident environment and protect residents from abuse. The facility will keep residents free from abuse, neglect, misappropriation of resident property and exploitation. This includes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observation, the facility did not provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Specifically, one resident was missing a personal item that was not located and not replaced. Resident identifier: 33. Findings include: Resident 33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dysthymic disorder, dysphagia, post-traumatic stress disorder, chronic obstructive pulmonary disease, a history of transient ischemic attacks, heart failure, anxiety, and diabetes. On 10/13/21 at 9:47 AM, resident 33 was interviewed. Resident 33 stated that he was missing a beautiful southwest blanket for over a month. Resident 33 stated that staff had looked for it, but could not find it. Resident 33 stated that he did not know the status of looking for his blanket and no resolution occurred. On 10/14/21, resident 33's medical record review was completed. Resident 33 had an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 28 sample residents, that the facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, a resident did not receive catheter care treatment after developing signs of a urinary tract infection (UTI) and after a positive urine culture. Resident identifier: 7. Findings include: Resident 7 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD), sepsis, benign prostatic hyperplasia (BPH), respiratory failure, and hypertension. Resident 7 was admitted to hospice services on 4/23/21. On 10/12/21 at 1:18 PM, resident 7 stated that he had problems with his catheter. Resident 7 stated that when staff worked with it, he experienced pain in his penis. On 10/14/21, resident 7's electronic medical record review was completed. Resident 7's physician orders included an order for a Foley catheter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 5 sample staff, that the facility did not conducted testing based on parameters. Specifically, a staff member was not tested twice weekly according to the community transmission rate. Staff identifiers: Staff 1. Findings include: According to the Center for Disease Control and Prevention (CDC) the community transmission was red on 9/20/21, 9/27/21, 10/4/21 and 10/12/21. https://covid.cdc.gov/covid-data-tracker/#county-view|Utah|49035|Risk|community_transmission_level According to the Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements revised on 9/10/21, routine staff testing for High (red) community transmission unvaccinated staff was required twice weekly. Staff testing was completed on 9/13/21, 9/16/21, 9/20/21, 9/23/21, 9/27/21, 9/30, 10/4/21, 10/7/21 and 10/11/21. Staff 1's testing was reviewed on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.