Monument Healthcare American Fork
350 East 300 North, American Fork, UT 84003 · Utah County · 106 certified beds · avg 21 residents/day · certified since Aug 21, 1984
Part of chain: MONUMENT HEALTH GROUP (11 facilities, chain avg rating 2.8★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Dec 6, 2023 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 17, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 6, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 17, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 6, 2023 · F-0692 · triggered by a complaint
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 17, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 6, 2023 · F-0867 · triggered by a complaint
The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Why it matters: Without a working quality program, the same care problems tend to repeat instead of getting fixed.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 17, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 28, 2022 · F-0677
The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Why it matters: Residents who don't get this help can suffer poor hygiene, skin breakdown, weight loss, and a loss of dignity.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 15, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 28, 2022 · F-0684
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 15, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (59)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Sep 4, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. · from a complaint |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint |
| Sep 4, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Dec 6, 2023 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Dec 6, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 6, 2023 | ▲ G · Actual harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Dec 6, 2023 | ▲ G · Actual harm, one-off | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility did not have firmly secured handrails on both sides of its hallways. · from a complaint |
| Dec 6, 2023 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. · from a complaint |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. · from a complaint |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · from a complaint |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to manage their own money and financial affairs. · from a complaint |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not properly hold, secure, and manage residents' personal money that was deposited with it for safekeeping. Facilities holding residents' funds must keep careful, honest accounts. · from a complaint |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them. · from a complaint |
| Dec 6, 2023 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. · from a complaint |
| Dec 6, 2023 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint |
| Feb 28, 2022 | ▲ G · Actual harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Feb 28, 2022 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Feb 28, 2022 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Feb 28, 2022 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 28, 2022 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 28, 2022 | D · Potential for harm, one-off | The facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand. |
| Feb 28, 2022 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Feb 28, 2022 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 28, 2022 | D · Potential for harm, one-off | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. |
| Feb 28, 2022 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Feb 28, 2022 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Feb 28, 2022 | D · Potential for harm, one-off | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Feb 28, 2022 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Feb 28, 2022 | D · Potential for harm, one-off | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Feb 28, 2022 | D · Potential for harm, one-off | The facility did not make sure resident rooms met each resident's needs. |
| Feb 28, 2022 | D · Potential for harm, one-off | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
| Feb 28, 2022 | D · Potential for harm, one-off | The facility had resident rooms without a window to the outside that meets the requirements. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (39 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 17 | 2 | G ▲ |
| 2023 | 39 | 4 | G ▲ |
| 2025 | 3 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $35,437.
| Date | Type | Amount / length |
|---|---|---|
| Dec 6, 2023 | Fine | $35,437 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Utah avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.06 | 3.87 | 3.95 | top 13% in Utah; top 12% in the U.S. |
| Registered Nurse hours | 2.17 | 1.17 | 0.69 | top 6% in Utah; top 1% in the U.S. |
| Weekend total nurse staffing | 4.08 | 3.39 | 3.50 | top 14% in Utah; top 21% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.37 | 0.88 | 0.48 | top 16% in Utah; top 2% in the U.S. |
| Total nursing staff turnover (%) | 50.0 | 50.7 | 45.8 | top 49% in Utah; bottom 38% in the U.S. |
| RN turnover (%) | 41.7 | 40.6 | 42.9 | top 49% in Utah; top 50% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.79, RN 2.49, weekend 4.67. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bennett, Tim | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Bennett, Tim | Individual | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
| Clawson, Travis | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Clawson, Travis | Individual | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
| Espinosa, Stephanie | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Espinosa, Stephanie | Individual | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
| Fragoso, Lindsay | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Fragoso, Lindsay | Individual | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
| Gunnison Valley Hospital | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2020 |
| Gunnison Valley Hospital | Organization | ADP of the SNF | NOT APPLICABLE | 07/03/2025 |
| Health Group Management LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Health Group Management LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/28/2025 |
| Marriott, Stephen | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Marriott, Stephen | Individual | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
| Monument Health Group LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Monument Health Group LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/28/2025 |
| Monument Health Properties LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
| Monument Real Estate American Fork LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
| Murray, Brian | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2020 |
| Ottley, Brett | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "How do you help residents maintain their daily living skills, and how do you measure whether it's working?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Stonehenge of American Fork | 1.1 mi | American Fork, UT | ★★★★☆ | 4/5 | |
| Mission at Alpine Rehabilitation Center | 3.2 mi | Pleasant Grove, UT | ★★☆☆☆ | 1/5 | abuseSFF |
| Pointe Meadows Health and Rehabilitation | 6.1 mi | Lehi, UT | ★★★★★ | 4/5 | |
| Cascades at Orchard Park | 7.3 mi | Orem, UT | ★★★★☆ | 4/5 | |
| Stonehenge of Orem | 7.3 mi | Orem, UT | ★★★★★ | 5/5 | |
| Orem Rehabilitation and Nursing Center | 9.6 mi | Orem, UT | ★★★☆☆ | 2/5 | |
| Aspen Ridge of Utah Valley | 10.2 mi | Orem, UT | ★★★★★ | 5/5 | |
| Draper Rehabilitation and Care Center | 10.3 mi | Draper, UT | ★★★★☆ | 4/5 | |
| Provo Rehabilitation and Nursing | 11.4 mi | Provo, UT | ★☆☆☆☆ | 1/5 | abuseSFF |
| Neurorestorative | 11.4 mi | Riverton, UT | ★★★★☆ | 3/5 | |
| Rocky Mountain Care - Riverton | 13.5 mi | Riverton, UT | ★★★★☆ | 3/5 | |
| Stonehenge of South Jordan | 14.4 mi | South Jordan, UT | ★★★★★ | 5/5 |
Compare this facility with the 3 closest →
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Facility data as of CMS processing date 2026-08-01. CCN 465097.