Monument Healthcare South Salt Lake
2472 South 300 East, Salt Lake City, UT 84115 · Salt Lake County · 140 certified beds · avg 102 residents/day · certified since May 6, 1997
SFF Candidate
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: ★☆☆☆☆1/5 · CMS overall rating: 1/5
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)
▲ Immediate jeopardy, facility-wide · Jun 19, 2025 · 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 (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: Jun 30, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Jun 19, 2025 · F-0921
The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Why it matters: An unsafe or unclean environment raises the risk of falls, infections, and daily discomfort for residents.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Jun 30, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 19, 2025 · F-0742
The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD).
Why it matters: Residents with mental health needs who go untreated can suffer worsening symptoms, distress, and isolation.
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: Jun 30, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 25, 2024 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
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: Feb 15, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 21, 2022 · F-0600
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.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
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: May 6, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 21, 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: May 6, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 21, 2022 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
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: May 6, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 21, 2022 · F-0697
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
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: May 6, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 21, 2022 · F-0867
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: May 6, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (57)
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 |
|---|---|---|
| Jun 19, 2025 | ▲ L · Immediate jeopardy, facility-wide | 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 |
| Jun 19, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Jun 19, 2025 | ▲ G · Actual harm, one-off | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). |
| Jun 19, 2025 | F · Potential for harm, facility-wide | The facility did not provide timely, quality laboratory tests to meet residents' needs. |
| Jun 19, 2025 | 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. |
| Jun 19, 2025 | 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. |
| Jun 19, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jun 19, 2025 | 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. |
| Jun 19, 2025 | E · Potential for harm, repeated | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Jun 19, 2025 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Jun 19, 2025 | D · Potential for harm, one-off | 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 |
| Jun 19, 2025 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Jun 19, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jun 19, 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. |
| Jun 19, 2025 | D · Potential for 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. |
| Jun 19, 2025 | 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. |
| Jun 19, 2025 | 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. |
| Jun 19, 2025 | D · Potential for harm, one-off | The facility did not bring in qualified outside professionals to provide a required service when it didn't have a qualified professional on staff. |
| Jun 19, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Jun 19, 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. |
| Jan 25, 2024 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jan 25, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jan 25, 2024 | 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. |
| Jan 25, 2024 | 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. |
| Jan 25, 2024 | 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. |
| Jan 25, 2024 | 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. |
| Jan 25, 2024 | D · Potential for 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. |
| Jan 25, 2024 | 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. |
| Jan 25, 2024 | 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. |
| Mar 21, 2022 | ▲ G · Actual harm, one-off | 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. |
| Mar 21, 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. |
| Mar 21, 2022 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Mar 21, 2022 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Mar 21, 2022 | ▲ 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. |
| Mar 21, 2022 | F · Potential for harm, facility-wide | 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. |
| Mar 21, 2022 | F · Potential for harm, facility-wide | 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. |
| Mar 21, 2022 | E · Potential for harm, repeated | 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. |
| Mar 21, 2022 | E · Potential for harm, repeated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Mar 21, 2022 | 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. |
| Mar 21, 2022 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Mar 21, 2022 | 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. |
| Mar 21, 2022 | 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. |
| Mar 21, 2022 | 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. |
| Mar 21, 2022 | 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. |
| Mar 21, 2022 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Mar 21, 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. |
| Mar 21, 2022 | D · Potential for harm, one-off | 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. |
| Mar 21, 2022 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Mar 21, 2022 | 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. |
| Mar 21, 2022 | 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. |
| Mar 21, 2022 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. |
| Mar 21, 2022 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Mar 21, 2022 | D · Potential for 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. |
| Mar 21, 2022 | 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. |
| Mar 21, 2022 | 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. |
| Mar 21, 2022 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Mar 21, 2022 | D · Potential for harm, one-off | The facility's bedrooms did not give residents visual privacy — such as curtains or dividers — when privacy is needed. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (9 → 20).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 28 | 5 | G ▲ |
| 2024 | 9 | 1 | G ▲ |
| 2025 | 20 | 3 | L ▲ |
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)
2 fines totaling $36,546.
| Date | Type | Amount / length |
|---|---|---|
| Jun 19, 2025 | Fine | $18,155 |
| Jan 25, 2024 | Fine | $18,391 |
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) | 3.11 | 3.87 | 3.95 | bottom 19% in Utah; bottom 18% in the U.S. |
| Registered Nurse hours | 1.16 | 1.17 | 0.69 | top 40% in Utah; top 10% in the U.S. |
| Weekend total nurse staffing | 2.65 | 3.39 | 3.50 | bottom 12% in Utah; bottom 14% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.97 | 0.88 | 0.48 | top 30% in Utah; top 6% in the U.S. |
| Total nursing staff turnover (%) | 47.2 | 50.7 | 45.8 | top 42% in Utah; bottom 44% in the U.S. |
| RN turnover (%) | 45.2 | 40.6 | 42.9 | bottom 42% in Utah; bottom 43% 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 3.72, RN 1.39, weekend 3.18. Staffing rating: 3/5.
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: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
Government - Hospital district
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Gunnison Valley Hospital | Organization | Direct Ownership Interest | NOT APPLICABLE | 07/01/2020 |
| Clawson, Travis | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Clawson, Travis | 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 |
| Galindo, Michael | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Galindo, Michael | 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 | 03/11/2025 |
| Health Group Management LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Health Group Management LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/04/2025 |
| Lock, Chelsea | Individual | Operational/Managerial Control | NOT APPLICABLE | 02/07/2025 |
| Lock, Chelsea | Individual | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
| 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 | 02/07/2025 |
| Monument Health Properties LLC | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 02/07/2025 |
| Monument Health Properties LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/07/2025 |
| Monument Real Estate South Salt Lake LLC | Organization | 5% or Greater Mortgage Interest | 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.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
- "What mental health services do you offer on-site, and how do you care for residents with depression, anxiety, or a history of trauma?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
- "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 |
|---|---|---|---|---|---|
| Meadow Brook Rehabilitation and Nursing | 0.3 mi | Salt Lake City, UT | ★★☆☆☆ | 1/5 | abuse |
| St Joseph Villa | 0.8 mi | Salt Lake City, UT | ★★★☆☆ | 3/5 | |
| Little Cottonwood Rehabilitation and Nursing | 1.1 mi | South Salt Lake, UT | ★★★★★ | 5/5 | |
| Millcreek Rehabilitation and Nursing | 1.6 mi | Salt Lake City, UT | ★★☆☆☆ | 1/5 | abuse |
| Monument Healthcare Murray Creek | 2.1 mi | Millcreek, UT | ★★☆☆☆ | 1/5 | abuse |
| Paramount Health and Rehabilitation | 2.3 mi | Salt Lake City, UT | ★★★☆☆ | 2/5 | |
| Mt. Olympus Rehabilitation Center | 2.9 mi | Salt Lake City, UT | ★★☆☆☆ | 1/5 | |
| Maple Ridge Rehabilitation and Nursing | 3.0 mi | Salt Lake City, UT | ★☆☆☆☆ | 2/5 | abuse |
| Pine Creek Rehabilitation and Nursing | 3.0 mi | Salt Lake City, UT | ★★★☆☆ | 2/5 | abuse |
| Monument Healthcare Millcreek | 3.1 mi | Salt Lake City, UT | ★★★★☆ | 3/5 | |
| Alpine Meadow Rehabilitation and Nursing | 3.1 mi | West Valley City, UT | ★★★☆☆ | 2/5 | |
| City Creek Post Acute | 3.2 mi | Salt Lake City, UT | ★★★☆☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 465146.