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Four Corners Regional Care Center

818 North 400 West, Blanding, UT 84511 · Government - County · 104 certified beds · (435) 638-2251 Medicare & Medicaid certified

Call the home — (435) 638-2251 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Jan 2025Behavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations$68,471 in federal fines1 Medicare payment denial
Insights

The public record raises real questions here. Weigh the concerns below carefully.

Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $68,471 in federal fines (most recent 2025-01-09)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (67%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
E Highway 262 · (435) 651-3291 · Call to confirm hours
Pharmacy
65 S Main St · (435) 678-2781 · Call to confirm hours
Grocery
820 S Main St · (435) 678-2721 · Call to confirm hours
Park
(435) 678-2916 · Typically dawn to dusk

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased21.7%11.3%15.4%worse
Long-stay residents who lose too much weight3.9%3.4%5.4%better
Long-stay residents with a catheter left in their bladder1.8%0.7%0.9%worse
Long-stay residents with a urinary tract infection0.6%1.8%2.0%better
Long-stay residents with depressive symptoms28.2%16.5%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury3.3%2.5%3.3%typical
Long-stay residents whose ability to walk worsened18.1%15.1%16.1%worse
Long-stay residents on antianxiety or hypnotic medication6.0%25.3%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers1.8%3.9%4.7%better
Long-stay residents with worsening bladder/bowel control22.0%21.5%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table24.1%14.2%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.8%0.9%1.4%worse
Short-stay residents rehospitalized after admission14.9%16.5%22.6%better
Short-stay residents with an outpatient ER visit4.9%11.6%12.0%better
Long-stay hospitalizations per 1,000 resident days0.611.251.67better
Long-stay outpatient ER visits per 1,000 resident days2.821.431.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

46.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.2%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
0.20U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy

Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF46.2%CMS range 34.6–61.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 7.1–15.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.211.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.35
RN hours/ resident / day
0.74
LPN hours/ resident / day
1.82
Aide hours/ resident / day
2.91
Total nurse hours/ resident / day
0.11
RN hoursweekends
67.4%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 104 beds and averages 50.1 residents a day — about 48% occupied, or roughly 54 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.91 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.82 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.56 hrs/resident/day on weekends vs 3.05 on weekdays — 16% thinner on weekends. RN hours go from 0.45 to 0.11 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 67% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

14
deficiencies at the latest standard inspection (2025-01-09)
5
at the previous standard inspection (2023-03-15)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 12 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · Hcited before2025-01-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident 52 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease with dyskinesia, dementia, insomnia, monoplegia of upper limb, dysphagia, myalgia, and muscle spasms. Resident 52's medical record was reviewed on 1/6/25 through 1/9/25. A care plan Focus initiated on 7/31/19, documented [Resident 52] is High risk for falls r/t Parkinson's disease, poor safety awareness, impaired balance, impaired mobility, impulsiveness frequently taking all of his clothing out of the closet and drawers and throwing them on the floor. The Focus was revised and canceled on 12/27/23. No new fall interventions were implemented in 2023. An annual MDS assessment dated [DATE], revealed resident 52 had a BIMS score of 3, indicating significant cognitive impairment. The assessment also revealed resident 52 required one person extensive assistance for transfers, walking, and locomotion in the facility, and toileting. A fall risk assessment dated [DATE], determined that resident 52 was a high fall risk.…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2023-03-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined, the facility did not ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI). Specifically, for 1 out of 23 sampled residents, facility staff did not: promptly respond with the resident presented with signs and symptoms of a UTI; ensure the resident received an antibiotic susceptible to organism causing the UTI; and, obtain antibiotic order clarification when a disparity existed. Resident identifier: 10. Findings included: Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, senile degeneration of brain, dementia, atrial fibrillation, essential hypertension, insomnia, and cellulitis. Resident 10's medical record was reviewed on 3/14/23. A quarterly Minimum Data Set assessment dated [DATE], documented that resident 10 was occasionally incontinent of bladder and always continent of bowel. In addition,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-01-09 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility did not have the nurse staffing information posted. The facility must post the following information on a daily basis: Facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistant, and resident census. The facility must post the nurse staffing data on a daily basis at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Specifically, the nurse staffing data was not posted on a daily basis and the nurse staffing data was not complete. Findings included: On 1/6/25 at 4:21 PM, an observation of the nurse staffing information was completed. The nurse staffing information was dated 1/5/25, and did not include the actual hours of the licensed and unlicensed nursing staff. On 1/8/25 at 8:00 AM, an observation of the nurse staffing information was completed. The nurse staffing…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-09 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that alleged violations involving abuse were reported immediately but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to officials including the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, for 6 out of 39 sampled residents, allegations of resident to resident abuse and injuries of unknown origin were not reported timely to the SSA or APS. In addition, allegations of resident to resident sexual abuse and neglect were not reported to the SSA or APS. Resident identifiers: 13, 17, 31, 36, 49, and 53. Findings included: 1. Resident 13 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, hypertensive chronic kidney disease, asthma, heart failure,…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-09 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility in response to allegations of abuse, neglect, or mistreatment did not have evidence that all alleged violations were thoroughly investigated. Specifically, for 13 out of 39 sampled residents, allegations of resident to resident sexual abuse, injuries of unknown origin, and neglect were not investigated or the allegations were not investigated thoroughly. Resident identifiers: 13, 17, 32, 36, 46, 47, 48, 49, 50, 52, 51, 54, and 55. Findings included: 1. Resident 13 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, hypertensive chronic kidney disease, asthma, heart failure, major depressive disorder, essential hypertension, and pressure ulcer stage two. On 1/6/25 at 2:56 PM, an interview was conducted with resident 13. Resident 13 stated she had a resident to resident incident in the dining room the other day. Resident 13 stated that one little old man that ate in the dining room was a little on the horny side and he…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-09 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's) to meet the needs of each resident. Specifically, the facility staff were taping narcotic medications back into the medication cards. Findings included: On 1/8/25 at 8:00 AM, an observation was made of the facility Team 1 medication cart with Licensed Practical Nurse (LPN) 2. The following medications were observed in the medication cart: a. A multi dose medication card which held Oxycodone 5 milligram (mg) had the back of pocket numbers 26 and 27 that were opened with tape now closing them, there were no medications observed in the pockets. b. A multi dose medication card which held Hydrocodone - Acetaminophen 5-325 mg had the back of pocket number 34 that was opened with tape now closing it, there was no medication observed in the pocket. An immediate interview was conducted with LPN 2. LPN 2 stated the nurses would do the narcotic count at change 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-01-09 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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, food items in the walk-in freezer, walk-in refrigerator, and dry food storage room were open to the air and several areas throughout the kitchen had floor tiles that were damaged. Findings included: On 1/6/25 at 1:50 PM, an initial walk-through of the kitchen was conducted. In the walk-in refrigerator, three containers with green lids were observed to be without labels or dates. The tall container contained a thin, creamy liquid. One of the short containers contained a meat patty, and the other short container contained what appeared to be sliced meat. In the walk-in freezer, a box of cinnamon roll dough was found to be open to air. In the dry storage room, a box of bacon bits was open to air. An observation in the dish machine area revealed a large area from the drain on the floor to under the dish machine that had damaged floor covering and the cement was exposed. On 1/8/25 at 11:27 AM, a second…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-01-09 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 5 out of 39 sampled residents, a residents feeding tube was not capped when not in use, staff did not wear Personal Protective Equipment (PPE) while providing high contact care for residents on Enhanced Barrier Precautions (EBP), staff were not performing hand hygiene between resident care, and the Hoyer lift was not sanitized between resident use. Resident identifiers: 5, 19, 23, 29, and 348. Findings included: 1. Resident 348 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, encounter for surgical aftercare following surgery on the nervous system, hemiplegia, traumatic subarchnoid hemorrhage with loss of consciousness, gastrostomy status, pressure ulcer of right buttock stage 2, essential…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, for 1 out of 39 sampled residents, a resident who had experienced a significant weight loss did not have recommendations from the Registered Dietitian (RD) implemented. Resident identifier: 4. Findings included: Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, pneumonia, type 2 diabetes mellitus (DMII), asthma, essential hypertension, major depressive disorder, chronic pain, legal blindness, and adjustment disorder with depressed mood. Resident 4's medical record was reviewed on 1/7/25 through 1/9/25. A care plan Focus initiated on 4/14/21 and revised on 12/26/24, documented [name redacted] has nutritional problem or potential nutritional problem r/t [related to], therapeutic diet. She has DMII, she is…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director (MD), and the Director of Nursing (DON) were acted upon. Specifically, for 1 out of 39 sampled residents, a pharmacy recommendation to discontinue hydroxyzine was not acted upon timely. Resident identifier: 17. Findings included: Resident 17 was admitted to the facility on [DATE] with diagnoses which included hemiplegia affecting right dominant side, traumatic brain injury, dementia, unsteadiness on feet, foot drop of right foot, adult failure to thrive, sexual dysfunction, bilateral primary osteoarthritis of hip, and insomnia. Resident 17's medical record was reviewed on 1/6/25 through 1/9/25. A review of resident 17's physician orders revealed, hydrOXYzine HCl [hydrochloride] Oral Tablet 25 MG [milligrams] (Hydroxyzine HCl) Give 25 mg by mouth every 6 hours as needed for antianxiety. A review of resident 17's Patient Recommendations Summary -…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicated that the dose should be reduced or discontinued. Specifically, for 1 out of 39 sampled residents, a resident's medication was not discontinued per pharmacy and provider recommendations. Resident identifier: 17. Findings included: Resident 17 was admitted to the facility on [DATE] with diagnoses which included hemiplegia affecting right dominant side, traumatic brain injury, protein calorie malnutrition, dementia, unsteadiness on feet, foot drop of right foot, adult failure to thrive, sexual dysfunction, bilateral primary osteoarthritis of hip, and insomnia. Resident 17's medical record was reviewed on 1/6/25 through 1/9/25. A review of resident 17's physician…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-01-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    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. A GDR must be attempted in two separate quarters, with at least one month between attempts, within the first year in which an individual was admitted on a psychotropic medication or after the facility had initiated such medication, and then annually. Specifically, for 1 out of 39 sampled residents, a resident taking an anticonvulsant medication for behavioral disturbance had not received a GDR on that medication since 2023, and the medication was not clinically contraindicated. Resident identifier: 24. Findings included: Resident 24 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, senile degeneration of brain, dementia, essential hypertension, atrial fibrillation, and mood disorder. Resident 24's medical record was reviewed on 1/7/25 through…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2025-01-09 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not label all drugs and biological's used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, two vials of insulin were open and available for use past the expiration date. Findings included: On [DATE] at 7:40 AM, an observation was made of the Team 2 medication cart with Licensed Practical Nurse (LPN) 1, the following medications were located in the medication cart: a. A bottle of Lantus 100 units/milliliter (ml) was open and available for use and labeled with an open date of [DATE], wrote on the vial and a date of 1/7, written on the box. The vial was opened 8 days past the 28 day open date. b. A bottle of Tresiba 100 units/ml was open and available for use and labeled with an open date of [DATE], wrote on the vial and a date of 1/7, wrote on the box. This vial was opened 6 days past the 28 days open date. An immediate interview…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, for 1 out of 39 sampled residents, a resident had a urinalysis (UA) ordered and the urine was not collected for five days after the order was given. Resident identifier: 17. Findings included: Resident 17 was admitted to the facility on [DATE] with diagnoses which included hemiplegia affecting right dominant side, traumatic brain injury, protein calorie malnutrition, dementia, unsteadiness on feet, foot drop of right foot, adult failure to thrive, sexual dysfunction, bilateral primary osteoarthritis of hip, and insomnia. Resident 17's medical record was reviewed on 1/6/25 through 1/9/25. A physician's order revealed, Urine to reflex to culture ordered on 9/25/24 and discontinued on 9/26/24. The progress notes revealed: a. On 9/25/24 at 1:20 PM, .2) UA with reflex to Cx [culture]. b. On 9/30/24 at 4:40 PM, UA collected on resident with clean urinal. UA sent to labs and…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-01-09 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not maintain medical records on each resident that were accurately documented. Specifically, for 2 out of 39 sampled residents, a resident's medical record contained another resident's appeal discussion. Resident identifiers: 246 and 247. Findings included: 1. Resident 246 was admitted to the facility on [DATE] with diagnoses which included paraplegia, chronic obstructive pulmonary disease, spinal stenosis, anxiety disordered, intraspinal abscess, and granuloma. Resident 246's medical record was reviewed on 1/8/25. The review revealed that a medical record for resident 247 labeled KEPRO_5.23.23.pdf was in resident 246's medical record. 2. Resident 247 was admitted to the facility on [DATE] with diagnoses which included polyneuropathy, dementia of brain, spinal stenosis, anxiety disorder, and senile degeneration of the brain. Resident 247's medical record was reviewed on 1/8/25. On 5/23/23, resident 247's medical record had patient identifying information…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-15 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 2 out of 23 sampled residents, a staff member was observed to touch resident medications with bare hands with each medication administration. Resident identifiers: 2 and 22. Findings included: On 3/15/23 at 8:20 AM, an observation was made of Registered Nurse (RN) 1. RN 1 was observed to touch the desk chair, medication cart keys, medication cart, and computer immediately prior to resident medication administration. No hand hygiene (HH) was observed. RN 1 was then observed to place her ungloved fingers into a medication bottle and obtain a tablet. The tablet was then placed into a medication cup for administration. RN 1 was then observed to push a medication out of a bubble pack into her ungloved hand, pick the medication up with ungloved fingers, and…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined, the facility did not ensure that the residents environment remains as free of accident hazards as was possible. Specifically, for 1 out of 23 sampled resident, a resident fell in the transportation vehicle during a transport. Resident identifier: 21. Findings Included: Resident 21 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include end stage renal disease, vascular dementia, pulmonary fibrosis, essential hypertension, type 2 diabetes, dependence on renal dialysis, atherosclerotic heart disease, benign prostatic hyperplasia, gastro-esophageal, hyperkalemia, incontinence without sensory awareness, presence of coronary angioplasty. On 3/14/23, resident 21's medical record was reviewed. A significant change Minimum Data Set (MDS) assessment dated [DATE], was reviewed. The MDS revealed that resident 21 required one person physical assistance with limited assistance for bed mobility, transfers,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident 15 was admitted to the facility on [DATE] with diagnoses which included late onset Alzheimer's disease, dementia, narcolepsy, obstructive sleep apnea, restless leg disorder, mood disorder, essential hypertension, wandering, and spinal stenosis. A review of resident 15's physician's orders revealed the following: a. Haloperidol lactate concentrate 2 milligrams/milliliter (mg/ml), administer 2.5 ml (milliliters)by mouth every 12 hours PRN for agitation. The medication was initiated on 12/24/22, with an end date documented as indefinite. b. Haloperidol lactate 5 mg/ml, inject 2.5 ml intramuscularly every 12 hours PRN for agitation and aggression. The medication was initiated on 1/4/23, with an end date documented as indefinite. A review the MAR for December 2022, January 2023, and February 2023 revealed haloperidol was administered to resident 15 numerous times. Review of resident 15's medical record revealed no documentation of a physician evaluation, every 14 days, documenting the appropriateness 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-15 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined, the facility did not ensure that each resident's medical record included documentation that indicated that the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations; and that the resident either received the influenza and pneumococcal immunizations or did not receive the influenza and pneumococcal immunizations due to medical contraindications or refusal. Specifically, for 1 out of 23 sampled residents, a resident was not offered the pneumococcal immunization and the resident or the resident's responsible party was not provided information including the risks, benefits, and potential side effects of the pneumococcal immunization. Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, late onset Alzheimer's disease, dementia, narcolepsy, obstructive sleep…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-06-17 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility did not develop and implement a comprehensive person-centered care plan for 3 of 18 sample residents, that included measurable objectives and timeframes to meet the residents' medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident's care plan regarding assisting with dining was not implemented as written, and two residents did not have care plans developed regarding their need for assistance with dining. Resident identifiers: 9, 14, and 33. Findings include: 1. Resident 9 was admitted on [DATE] and readmitted on [DATE] with diagnoses of quadriplegia, contracture on the right hand, diabetes mellitus, abnormal posture, and muscle spasms. Resident 9's medical record was reviewed on 6/14/21. An annual Minimum Data Set (MDS) for resident 9 dated 3/17/21 was reviewed. Staff assessed resident 9 as being totally dependent on staff for eating, dressing, bed mobility, transfers, personal hygiene,…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-06-17 · tag F0677 — failed to help fully-dependent residents with daily care — pattern
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not provide services to maintain good nutrition, grooming, and personal hygiene for 4 of 18 sample residents where were unable to carry out those activities of daily living. Specifically, residents were not provided timely assistance with meals. Resident identifiers: 9, 14, 16, and 33. Findings include: 1. Resident 9 was admitted on [DATE] and readmitted on [DATE] with diagnoses of quadriplegia, contracture on the right hand, diabetes mellitus, abnormal posture, and muscle spasms. Resident 9's medical record was reviewed on 6/14/21. An annual Minimum Data Set (MDS) for resident 9 dated 3/17/21 was reviewed. Staff assessed resident 9 as being totally dependent on staff for eating, dressing, bed mobility, transfers, personal hygiene, bathing, and toilet use. Review of resident 9's Care plan dated 1/3/19 revealed that resident 9 was totally dependent on staff for eating. On 6/15/21, the lunch meal was observed in the main dining room. Resident 9's…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-17 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and observation, the facility did not review and revise 1 of 18 sample resident's care plans after each assessment. Specifically, one resident had 12 falls with the care plan updated 4 times. Additionally, staff did not implement the resident's care plan effectively. Resident identifier: 22. Findings include: Resident 22 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, dementia, atrial fibrillation, hypertension, insomnia, and a history of falls. On 6/14/21, resident 22 was observed in her wheelchair. Resident 22 was observed to have confusion, and subsequently, resident 22's family member (FM) 1 was interviewed. FM 1 stated that resident 22 had experienced multiple falls and the family was concerned about the level of monitoring provided by staff. On 6/17/21, resident 22's electronic medical record review was completed. Resident 22 had assessments for to determine her risk for falling. The initial assessment was completed on 9/28/21…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-17 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined for 1 of 18 sample residents that the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Resident identifier 16. Findings include: Resident 16 was admitted to the facility on [DATE] with diagnoses which included quadriplegia incomplete, spastic hemiplegia affecting right dominant side, and major depressive disorder. On 06/14/21 at 4:40 PM, resident 16's medical record was reviewed and revealed the following doctor's orders: Right hand splint/rolled wash cloth to be donned daily for six hours: On at 0800, off at 1400 (2 PM) one time a day. Start Date 12/13/2018 0800 (8:00 AM). Left hand splint (blue soft splint) to be donned at night when in bed one time a day for contracture management and prevention of skin breakdown. Start Date 10/16/2019 1915 (7:15 PM). Resident 16 was observed lying in her bed at the…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-06-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined for 1 of 18 sample residents, that the facility did not ensure that the resident's environment remained as free of accident hazards as was possible; and that the resident received adequate supervision and assistance devices to prevent accidents. Specifically, one resident had multiple falls without interventions. Resident identifier: 22. Findings include: Resident 22 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, a history of falls, osteoarthritis, and diabetes mellitus with retinopathy. On 6/14/21, resident 22 was observed in her wheelchair. Resident 22 was observed to have confusion, and subsequently, resident 22's family member (FM) 1 was interviewed. On 6/15/21 at 9:24 AM, FM 1 stated that resident 22 had multiple falls while at the facility and the family was concerned about the level of monitoring provided by staff. On 6/17/21, resident 22's electronic medical record review was completed. 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-17 · tag F0712 — isolated
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that 1 of 18 sample residents saw a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. Specifically, a resident had not been seen by the physician for approximately 6 months. Resident identifier: 33. Findings include: Resident 33 was admitted on [DATE] with diagnoses that included Alzheimer's disease, dementia, restlessness, and hypertensive chronic kidney disease. Resident 33's medical record was reviewed on 6/14/21. Resident 33's medical record included physician notes dated 10/13/20, 11/10/20 and 12/15/20. There was no documentation to indicate that the resident's physician had seen the resident since 12/15/20. On 6/16/20, an interview was conducted with the facility Director of Nursing (DON). The DON stated that if the physician had seen the resident, the notes should have been in the resident record.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-06-17 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that 2 of 18 sample residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Resident identifiers: 30 and 33. Findings include: 1. Resident 30 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia with behavioral disturbance, depression, anxiety, high blood pressure, chronic obstructive pulmonary disease (COPD), and left artificial hip joint. On 6/17/21, resident 30's electronic medical record was reviewed. On 8/29/19, resident 30 had a Preadmission Screening Resident Review (PASRR) level II evaluation. The history of psychiatric symptoms revealed that resident 30's Alzheimer's was too far progressed to do an evaluation and overrides any mental health diagnosis at this time. Resident 30's physicians orders revealed the following: a. On 12/12/2020, Olanzapine (Zyprexa) tablet, 10…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$68,471 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $68,471 — penalty dated 2025-01-09
  • Medicare payment denial — starting 2025-02-13 for 8 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to CASCADES HEALTHCARE — 19 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 51.9-0.9 vs chain
Health inspection 2 of 51.7+0.3 vs chain
Staffing 1 of 52.1-1.1 vs chain
Quality measures 4 of 54.1≈ chain avg
The other 18 homes this chain runs (chain average 1.9★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
MCSPADDEN, DARINIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
BARNEY, JANETTIndividualCORPORATE DIRECTORsince 09/18/2018
BROWN, GARYIndividualCORPORATE DIRECTORsince 09/18/2018
FULLMER, CHADIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
OAKDEN, RICHARDIndividualCORPORATE DIRECTORsince 09/18/2018
ROBINSON, MATTHEWIndividualCORPORATE DIRECTORsince 09/18/2018
SMITH, VALIndividualCORPORATE DIRECTORsince 09/18/2018
WHITE, CRAIGIndividualCORPORATE DIRECTORsince 09/18/2018
LANGFORD, SCOTTIndividualCORPORATE OFFICERsince 09/18/2018
CASCADES HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
JONES, LLOYDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/18/2018
STOKES, SAMUELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023

CMS files one row per role, so the 20 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$6.0M
Net patient revenuemost recent cost report
-0.0%
Operating marginrevenue minus expenses
$213K
Related-party expense4% of expenses
Who pays — share of resident-days
Medicaid 87%Medicare 7%Other / private 6%

About 87% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $213K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$358per resident / day
operating cost
$10,878per month
≈ monthly operating cost
$358per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in UT

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Utah Medicaid page.

Typical monthly cost in Utah
$8,669/mo
Nursing home (semi-private)
$10,646/mo
Nursing home (private)
$5,475/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 465057. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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