Cycle 1
Health 2024-12-18 · Fire 2024-12-18
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Bountiful, UT
Monument Healthcare Bountiful
2-star overall rating with 2-star inspections with $68,994 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
460 West 2600 South, Bountiful, UT
(801) 295-3135
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
71
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Monument Health Group
Operator or chain grouping
Approved since
1987-05-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.69
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.50
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.06
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
5,304
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9900
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.80
Baseline 17.59% · Performance 18.28% · Measure score 6.80 · Achievement 6.80 · Improvement 0
Healthcare-associated infections
5.98
Baseline 5.20% · Performance 6.05% · Measure score 5.98 · Achievement 5.98 · Improvement 0
Total nurse turnover
0
Baseline 57.14% · Performance 65.45% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.89
Baseline 3.65 hours · Performance 3.61 hours · Measure score 1.89 · Achievement 1.89 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.51% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 6.19% · Lower 95% interval 7% |
| Discharge to community | 67.58% |
50.57%
17 pts better
|
Better than the National Rate · Eligible stays 108 · Observed rate 66.67% · Lower 95% interval 59.96% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 88.14% |
95.27%
7.1 pts worse
|
Numerator 52 · Denominator 59 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 59 |
| Discharge self-care score | 48.89% |
53.69%
4.8 pts worse
|
Numerator 22 · Denominator 45 |
| Discharge mobility score | 42.22% |
50.94%
8.7 pts worse
|
Numerator 19 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 3.39% |
2.29%
1.1 pts worse
|
Numerator 2 · Denominator 59 · Adjusted rate 3.95% |
| Healthcare-associated infections requiring hospitalization | 6.05% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 2.86% · Lower 95% interval 3.63% |
| Staff COVID-19 vaccination coverage | 2.22% |
8.2%
6 pts worse
|
Numerator 2 · Denominator 90 |
| Staff flu vaccination coverage | 33.85% |
42%
8.1 pts worse
|
Numerator 44 · Denominator 130 |
| Discharge function score | 42.22% |
56.45%
14.2 pts worse
|
Numerator 19 · Denominator 45 |
| Transfer of health information to provider | 90% |
95.95%
6 pts worse
|
Numerator 18 · Denominator 20 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 20.69% |
25.2%
4.5 pts worse
|
Numerator 6 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.1 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
96.8%
2.2 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 97.8% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.1% |
98.0%
3.9 pts worse
|
95.5%
1.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
2.6%
1.1 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.2% · Q4 1.7% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.8% |
16.1%
7.3 pts better
|
11.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 14.6% · Q3 4.7% · Q4 7.0% · 4Q avg 8.8% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
3.8%
0.4 pts worse
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 12.1% · Q4 2.6% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.3% |
24.1%
3.2 pts worse
|
19.6%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 22.2% · Q3 27.3% · Q4 28.6% · 4Q avg 27.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.1% |
15.4%
10.3 pts better
|
16.7%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 15.0% · Q3 4.0% · Q4 3.2% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.0% |
18.3%
10.7 pts worse
|
16.3%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.8% |
13.6%
1.2 pts worse
|
14.9%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 25.8% · Q3 19.4% · Q4 2.6% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
1.8%
0.9 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.3% · Q3 2.2% · Q4 1.8% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.0% |
22.4%
4.4 pts better
|
19.8%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 25.9% · Q3 15.5% · Q4 12.0% · 4Q avg 18.0% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
4.1%
2.1 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 12.2% · Q3 5.0% · Q4 2.3% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
93.3%
6.4 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
11.8%
3 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 9.1% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
0.9%
0.7 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 1.9% · Q4 1.3% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.1% |
91.0%
14.9 pts worse
|
79.7%
3.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.1% |
17.4%
8.3 pts better
|
23.9%
14.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 9.1% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-16 · Fire 2023-03-16
5 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-08-18 · Fire 2022-08-18
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-18
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-01-07
Inspection history
Recent health citations
J · Immediate jeopardy
2025-11-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-06
D · Potential for more than minimal harm
2025-11-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-01-06
D · Potential for more than minimal harm
2025-11-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-06
G · Actual harm
2025-06-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-10
D · Potential for more than minimal harm
2025-06-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-17
G · Actual harm
2024-12-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-20
G · Actual harm
2024-12-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-12-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-18
F779 · Administration Deficiencies
Health
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
Corrected 2025-01-20
D · Potential for more than minimal harm
2024-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-23
E · Potential for more than minimal harm
2023-03-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-04-25
E · Potential for more than minimal harm
2023-03-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-25
E · Potential for more than minimal harm
2023-03-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-25
D · Potential for more than minimal harm
2023-03-16
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-04-25
D · Potential for more than minimal harm
2023-03-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-25
E · Potential for more than minimal harm
2022-08-18
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-09-22
E · Potential for more than minimal harm
2022-08-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-09-22
E · Potential for more than minimal harm
2022-08-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-22
D · Potential for more than minimal harm
2022-08-18
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-09-22
D · Potential for more than minimal harm
2022-08-18
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2022-09-22
Penalties and ownership
What sits behind the stars
$48,980
2025-11-06
Fine
Fine · fine $48,980
Fine
$0
2025-11-06
Payment Denial
Payment Denial · denial start 2025-12-30 · 7 days
7 day denial
$11,190
2025-06-09
Fine
Fine · fine $11,190
Fine
$8,824
2024-12-18
Fine
Fine · fine $8,824
Fine
Ownership
Milford Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Clawson, Travis
Operational/Managerial Control · Individual
Espinosa, Stephanie
Operational/Managerial Control · Individual
Fragoso, Lindsay
Operational/Managerial Control · Individual
Health Group Management LLC
Operational/Managerial Control · Organization
Marriott, Stephen
Operational/Managerial Control · Individual
Milford Memorial Hospital
Operational/Managerial Control · Organization
Monument Health Bountiful LLC
5% Or Greater Mortgage Interest · Organization
Monument Health Group LLC
Operational/Managerial Control · Organization
Monument Health Properties LLC
5% Or Greater Mortgage Interest · Organization
Moss, Tyler
Corporate Officer · Individual
Murphy, Cory
Operational/Managerial Control · Individual
Nixon, Tyler
Operational/Managerial Control · Individual
Olney, Kayla
Operational/Managerial Control · Individual
Robertson, Brett
Operational/Managerial Control · Individual
Samuelian, Spencer
Operational/Managerial Control · Individual
Seastrand, Jason
Operational/Managerial Control · Individual
West, Christian
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
South Davis Specialty Care
Bountiful, UT
5-star overall rating with 4-star inspections with 4 recent health deficiencies
#2
Monument Healthcare Stonecreek
Bountiful, UT
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Midtown Manor
Salt Lake City, UT
3-star overall rating with 2-star inspections with 21 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out