Monument Healthcare Stonecreek
523 North Main Street, Bountiful, UT 84010 · For profit - Limited Liability company · 122 certified beds · (801) 951-2273 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607) — 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 (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- about 56% of its spending goes to commonly-owned related companies
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 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
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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 | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 improved from 4 to 5 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.9% | 11.3% | 15.4% | typical |
| Long-stay residents who lose too much weight | 1.7% | 3.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.9% | 0.7% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 2.4% | 1.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 4.6% | 16.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.5% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 14.0% | 15.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 19.8% | 25.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.8% | 3.9% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 15.2% | 21.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.5% | 14.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.2% | 0.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 89.1% | 91.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 32.1% | 16.5% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.4% | 11.6% | 12.0% | typical |
‡ 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.
58.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 128 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 37.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 51 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.27 therapist hours per resident per day in 2025Q4 — more than 41% of the 13,714 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 21% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 14% — 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.8%CMS range 50.9–66.1 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.2–14.9 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 37.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 45.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 29.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 95.7% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 3.9–11.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.12 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 122 beds and averages 77.1 residents a day — about 63% occupied, or roughly 45 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 3.54 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.39 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.84 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 3.28 hrs/resident/day on weekends vs 3.84 on weekdays — 14% thinner on weekends. RN hours go from 1.49 to 1.05 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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
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.
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.
27 citations, most serious first. The 12 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · G2026-06-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 ensure each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, for 1 out of 40 sampled residents, the facility did not implement pressure ulcer interventions to prevent infection and new ulcers from developing. This will be cited at a harm level. Resident identifier: 3. Findings included:Resident 3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included pressure ulcer of sacral region stage 4, pressure ulcer of right buttock stage 4, pressure ulcer of left buttock stage 4, and pressure ulcer of left heel.Resident 3's Minimum Data Set (MDS) completed on 3/26/26 showed a Brief Interview of Mental Status (BIMS) score of 99. A score of 99 indicated the resident was unable to complete the assessment. Resident 3's MDS section GG…
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.
- Actual harm · Gcited before2024-01-03 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 for 1 of 5 sampled residents, that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive assessment, the comprehensive person-centered care plan, and the resident's preferences. Specifically, a resident with multiple co-morbidities who had a change in condition, was hospitalized after failure to identify the change in condition in a timely manner. The deficient practice for resident 1 was found to have occurred at a harm level. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included non-traumatic subdural hemorrhage, encephalopathy, epilepsy, end stage renal disease, hemiplegia and hemiparesis following cerebral infarct, history of falling, attention and concentration deficit following non-traumatic subarachnoid hemorrhage, Alzheimer's disease, dementia, and schizophrenia. Resident…
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.
- Potential for harm · E2026-06-25 · tag F0554 — patternAllow residents to self-administer drugs if determined clinically appropriate.
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 ensure that the resident right to self-administer medications was clinically appropriate and safe. Specifically for 4 out of 40 sampled residents, residents were observed to have medications in their rooms and were not evaluated to determine if they were safe to self-administer medications. Resident identifiers: 8, 22, 35, and 78.Findings included:1. Resident 8 was admitted to the facility on [DATE] with diagnoses which included fracture of left femur, difficulty in walking, and muscle weakness.On 6/22/26 at 9:21 AM, a concurrent observation and interview were conducted with resident 8. On resident 8's bedside table there was a bottle of turmeric tablets and one white tablet. Resident 8 stated that the facility gave him a bunch of pills and he was unsure what the white tablet was. Resident 8 stated that he better take the white pill. A self administration evaluation or an order to self administer medications was not located.On 6/24/26 at…
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.
- Potential for harm · E2026-06-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide 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 observation, interview, and record review, the facility did not ensure each resident who entered the facility with an indwelling catheter or subsequently received one was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization was necessary. Specifically, for 3 out of 40 sampled residents, the facility did not discontinue residents' Foley catheters when there were no indications for use. Additionally, facility staff were not trained on the use of a PureWick for a resident and the PureWick tubing was observed draped over the head of the bed and not able to down drain. Resident identifiers: 3, 46, and 98.Findings included:1. Resident 3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included encephalopathy, altered mental status, type 2 diabetes, and dysphagia oropharyngeal phase.On 6/22/26 at 8:50 AM, an observation was made of resident 3. Resident 3 had a urinary catheter…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-06-25 · tag F0775 — patternKeep complete, dated laboratory records in the resident's record.
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 file in the resident's clinical record the laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, for 3 out of 40 sampled residents, laboratory results were not located in the medical record. Resident identifiers: 4, 46, and 99.Findings included:1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included dependence on renal dialysis, type 2 diabetes, and anemia in chronic kidney disease.Resident 4's physician's orders revealed the following:a. On 5/15/26, Admit labs: CBC [complete blood count], CMP [comprehensive metabolic panel], prealbumin, Hga1c [hemoglobin A1C], TSH [thyroid stimulating hormone] one time only for 1 Day.b. On 5/18/26, repeat CBC one time only for 1 day.c. On 5/19/26, Repeat CBC one time only for 1 dayIt should be noted that no laboratory results could be located in the medical record.2. Resident 99 was admitted to the facility on [DATE] and readmitted to…
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.
- Potential for harm · E2026-06-25 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, food items in the refrigerator and freezer were undated and opened to air. Additionally, food items in resident refrigerators were undated and/or expired.Findings included:1. On 6/22/26 at 7:41 AM, the initial tour of the kitchen was conducted. The following were observed:a. In the freezer was an opened bag of chicken breasts that were undated.b. In the freezer was a bag of raisin swirl bread that was opened and undated.c. In the refrigerator was an expired small carton of milk with the use by date of 5/9/26.2. On 6/22/26 at 10:25 AM, the resident refrigerators were observed. The following were observed:a. In the 100 hall resident refrigerator there was an expired yogurt container with a use by date of 6/14/26.b. In the 100 hall resident refrigerator there were four expired yogurt containers with a use by date 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.
- Potential for harm · D2026-06-25 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
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 who was given a psychotropic drug had adequate monitoring of that drug. Specifically, for 1 out of 40 sampled residents, a resident receiving an antidepressant did not receive a gradual dose reduction (GDR) in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. Resident identifier: 35.Findings included:Resident 35 was admitted to the facility on [DATE] with a diagnosis which included major depressive disorder. A physician's order dated 9/12/25, documented DULoxetine HCL [hydrochloride] Capsule Delayed Release Particles 30 MG [milligrams]. Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE . for 7 Days THEN Give 2 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE . The physician's order was discontinued on 9/24/25.A physician's order dated 9/24/25, documented DULoxetine HCl Capsule Delayed Release…
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.
- Potential for harm · D2026-06-25 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 implement written policies and procedures on prohibiting and preventing abuse and investigating any such allegations. Specifically, for 1 out of 40 sampled residents, staff were aware of allegations of roughness during care but did not escalate the allegation up the chain of command to be investigated as a possible allegation of abuse. Resident identifier: 46. Findings included:Resident 46 was admitted to the facility on [DATE] with diagnoses which included fibromyalgia, alcoholic cirrhosis, hepatic failure, generalized anxiety disorder, major depressive disorder, and chronic pain syndrome.On 6/22/26 at 9:55 AM, an interview was conducted with resident 46. Resident 46 stated that a staff member previously provided rough care during a brief change and persisted despite resident 46's request to stop. Resident 46 stated that this staff member was no longer allowed to work with her. Resident 46 stated that she did not want to disclose the staff member'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.
- Potential for harm · D2026-06-25 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 that the facility did not document in the resident's medical record the information that was provided to the receiving provider which must include a minimum of the practitioner responsible for the care of the resident; the resident representative contact information; advanced directive information; comprehensive care plan; a copy of the resident discharge summary; and all necessary information to ensure a safe and effective transition of care. Specifically, for 2 out of 40 sampled residents, the facility did not document in the resident's medical record the information conveyed to the receiving provider when the resident was transferred to the Emergency Room. Resident identifiers: 18 and 54.Findings included:1. Resident 54 was admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses which consisted of asthma, pneumonia, type 2 diabetes mellitus, congestive heart failure, hypertension, and chronic kidney disease. On 6/22/26 at 11:48 AM,…
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.
- Potential for harm · D2026-06-25 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
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 ensure that the services provided met professional standards of quality. Specifically, for 1 out of 40 sampled residents, a resident's tube feeding was labeled with an incorrect formula, an incorrect administration rate, and was not labeled with the initials of the nurse who initiated the infusion. Furthermore, additional tube feedings were missing required labeling information. Resident identifier: 3.Findings included:Resident 3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included encephalopathy, altered mental status, type 2 diabetes, and dysphagia oropharyngeal phase.A review of resident 3's physician orders revealed:a. On 6/3/26, an order for Enteral Feed Order every 24 hours for enteral feed administer Jevity 1.5 at 60 ml [milliliters] continuously.b. On 6/9/26, an order for Enteral Feed Order every day and night shift Flush feeding tube with 100 cc [cubic centimeter] of water q…
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.
- Potential for harm · D2026-06-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 interview and record review, the facility did not ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, for 1 out of 40 sampled residents, a resident did not receive bathing assistance per their schedule. Resident identifier 46. Findings included:Resident 46 was admitted to the facility on [DATE] with diagnoses which included fibromyalgia, alcoholic cirrhosis, hepatic failure, generalized anxiety disorder, major depressive disorder, and chronic pain syndrome.On 6/22/26 at 9:58 AM, an interview was conducted with resident 46. Resident 46 stated she had not had a bed bath in a week. Resident 46 stated that she required 2 staff to assist with bathing cares and the staff had reported not having enough time to complete the task. Resident 46 stated she was supposed to have bed baths 3 times a week and she had been provided one bed bath in the last 2 weeks. Resident…
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.
- Potential for harm · Dcited before2026-06-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 interview and record review, for 2 out of 40 sampled residents, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident left the facility and called his daughter to report he was lost and a week later another resident, who needed to be supervised during a Leave of Absence, left the facility. Resident identifiers: 29 and 110.Findings included:1. Resident 110 was admitted to the facility on [DATE] and discharged on 3/27/26 and readmitted on [DATE] and discharged on 6/2/26 with diagnoses which included depression, alcohol dependence, and history of transient ischemic attack. The facility reported to the State Survey Agency (SSA) on 5/22/26 at 11:32 AM, that resident 110 took an uber to get a haircut and called his daughter because he did not know how to get back on 5/14/26 at 11:35 AM. The daughter called the facility and they went and picked him up. It should be noted the incident happened on 5/21/26, not 5/14/26 as…
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.
Show the remaining 15 citations
- Potential for harm · Dcited before2026-06-25 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 pain management was provided to residents who required such services, consistent with professional standards of practice, the person-centered care plan and the residents' goals and preferences. Specifically, for 1 out of 40 sampled residents, a resident reported that his Tramadol dose was frequently administered late and it impacted his pain control. Resident identifier: 54. Findings included:Resident 54 was admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses which included asthma, pneumonia, type 2 diabetes mellitus, congestive heart failure, hypertension, chronic kidney disease, and low back pain. On 6/22/26 at 11:51 AM, an interview was conducted with resident 54. Resident 54 stated that he had pain in his lower back, bilateral knee pain, and coccyx related to a pressure ulcer. Resident 54 stated he took Tramadol and Tylenol for pain. Resident 54 stated that the dose of Tramadol was frequently administered late…
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.
- Potential for harm · D2026-06-25 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
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 must ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 40 sampled residents, a resident receiving dialysis had incomplete communication notes. Resident identifier: 4.Findings included:Resident 4 was admitted to the facility on [DATE] with diagnoses which included dependence on renal dialysis, type 2 diabetes, and anemia in chronic kidney disease.A review of resident 4's physician orders revealed:a. An order with a start date of 5/18/26, documented, COMPLETE the Dialysis Post Assessment Form after resident returns from dialysis. Ensure resident returns from dialysis with the Pre-Dialysis Assessment and Communication Form. Review and follow up as indicated. Call Dialysis center if not returned with resident. every day shift every Mon [Monday], Wed [Wednesday], Fri…
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.
- Potential for harm · Dcited before2026-06-25 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 residents were free of any significant medication errors. Specifically, for 1 out of 40 sampled residents, a resident taking a phosphate binder was not administered the medication with meals. Resident identifier: 4.Findings included:Resident 4 was admitted to the facility on [DATE] with diagnoses which included dependence on renal dialysis, type 2 diabetes, and anemia in chronic kidney disease.On 6/23/26 at 8:38 AM, an interview was conducted with resident 4. Resident 4 stated that she had been receiving her phosphate binder before and after meals and not with meals as she should be taking them. Resident 4 stated the medication needed to bind the phosphates in her food so her body did not absorb them. Resident 4 stated that she ate her meals in her room.A review of resident 4's physician orders revealed:a. On 5/14/26, Sucroferric Oxyhydroxide 500 MG [milligram] Tablet Give 2 tablet by mouth three times a day for Phosphorus Binder With meals (08…
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.
- Potential for harm · Dcited before2026-06-25 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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
Based on observation and interview, the facility did not ensure that all drugs and biologicals were stored in compartments under proper temperature controls. Specifically, observations were made of multiple medications stored in a refrigerator that had a registered temperature of 24 degrees Fahrenheit (F). Resident identifiers: 5, 41, 46, and 73. Findings included:On 6/24/26 at 9:27 AM, an observation was made of the medication refrigerator on 300/400 hallway with Registered Nurse (RN) 3. The internal temperature gauge read 24 degrees Fahrenheit (F). RN 3 stated that temperature was not in the safe zone as indicated on the thermometer which was between 34-40 degrees. RN 3 stated that at a temperature of 24 degrees F they risked having the medication freeze. RN 3 stated that she would adjust the temperature and check the thermometer again later. The following medications were observed inside the refrigerator on 6/24/26 at 9:27 AM.Resident 5's Insulin Lispro 100 unit /milliliter (ml) - 5 pens totalResident 5's Insulin Lispro 100 unit/ml - 3 vialsResident 73's Admelog solostar 100…
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.
- Potential for harm · D2026-06-25 · tag F0779 — isolatedKeep signed and dated reports of x-rays and other diagnostic services in the residents record.
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 file in the resident's medical record signed and dated reports of radiological services. Specifically, for 1 out of 40 sample residents, a resident's Electrocardiogram (EKG) report was not located in the medical record. Resident identifier: 99.Findings included:Resident 99 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included unspecified kidney failure, thrombocytopenia, and chronic myelomonocytic leukemia.On 6/1/26 at 4:49 PM, an order note documented, STAT [immediate] order for EKG due to HR [heart rate] ranging from 37 to 54, she also has been having N [nausea] .It should be noted that an EKG report was not located in resident 99's medical record.On 6/24/26 at 3:53 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated the EKG was not in the resident's medical record and the facility had to call and get the results.
- Potential for harm · D2026-06-25 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 observation and interview, the facility did not keep confidential all information contained in the resident medical records and safeguard against unauthorized access. Specifically, observations were made of the licensed nurse leaving the computer unattended and open to resident medical records and leaving the report sheet with resident health information unattended and visible on the medication cart.Findings included: On 6/24/26 at 8:15 AM, an observation was made of Registered Nurse (RN) 8 during the morning medication administration. RN 8 was observed to leave her report sheet unattended and visible on the medication cart outside room [ROOM NUMBER]. A resident roster with health information was visible to passersby. At 8:34 AM, RN 8 walked away from the medication cart to obtain additional medication. RN 8's nurse report sheet and computer were left unattended, open and resident identifiable health information was visible to passersby. An immediate interview was conducted with RN 8 upon her return to…
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.
- Potential for harm · D2026-06-25 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment. Specifically, for 2 out of 40 sampled residents, personal protective equipment (PPE) was not worn for high contact care for residents on Enhanced Barrier Precautions (EBP). Resident identifiers: 3 and 15.Findings included:1. Resident 3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included encephalopathy, altered mental status, type 2 diabetes, and dysphagia oropharyngeal phase.On 6/25/26 at 7:27 AM, an observation was made of Registered Nurse (RN) 1 administering medications to resident 3 through her Nasogastric tube and was not wearing a gown.On 6/25/26 at 8:22 AM, an interview was conducted with RN 1. RN 1 stated that EBP PPE included wearing gloves and a gown. RN 1 stated that EBP was used for any resident that had a urinary catheter, feeding tube, or wounds. RN…
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.
- Potential for harm · Dcited before2026-01-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
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 for 1 out of 8 sampled residents, the facility did not ensure that all residents received the treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, a resident was not provided wound vac supplies in a timely manner. Resident identifier: 2.Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included, encounter for orthopedic aftercare, acquired absence of left great toe, and type 2 diabetes.A review of resident 2's medical record revealed the following:a. On 6/5/25 at 7:02 PM, a progress note documented, Resident back from wound clinic appointment from [local hospital]. Notes state to order wound vac, and send it with patient to next appointment and doctor wants patient to do hyperbaric oxygen therapy, team at [facility] needs to talk about a decision. Resident aware of orders. DON [Director of Nursing] [name…
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.
- Potential for harm · D2026-01-05 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 out of 8 sampled residents, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, residents were not provided multiple medications due to them being out of stock and unavailable from the pharmacy. Resident identifiers: 2 and 8.Findings included: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included, encounter for orthopedic aftercare, acquired absence of left great toe, and type 2 diabetes.Resident 2's medical record was reviewed on 1/5/26.A review of resident 2's medication orders revealed:a. Glimepiride Oral Tablet 4 MG [milligram] Give 4 mg by mouth at bedtime for T2DM [Type 2 diabetes mellitus]. The start date of this medication was 5/15/25.b. Eucerin Advanced Repair External Cream (Emollient) Apply to [NAME] [bilateral] Lower extremites [sic] topically two times a day for Dry scaley [sic] skin. The start date of this medication was 5/26/25. c. Amitriptyline HCI…
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.
- Potential for harm · Dcited before2026-01-05 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 residents were free of any significant medication errors. Specifically, 1 out of 8 sampled residents did not receive their intravenous (IV) antibiotics every 8 hours as ordered by the hospital. Resident identifier: 2. Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included, encounter for orthopedic aftercare, acquired absence of left great toe, and type 2 diabetes.Resident 2's medical record was reviewed on 1/5/26.A review of resident 2's hospital discharge orders dated 5/15/25 at 1:08 PM, documented Cefazolin 2 GM [gram] (TRADE NAME: ANCEF 2 GM/100 ML [milliliters] IVPB) [intravenous piggyback] INTRAVENOUS EVERY 8 HOURS 50 days. The last dose was documented as being received on 5/15/25 at 7:24 AM at the hospital.A review of resident 2's medication orders revealed: a. On 5/15/25 an order for CeFAZolin Sodium Solution Reconstituted 1 GM Use 2 gram intravenously every 24 hours for infection for 50 Days.b.…
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.
- Potential for harm · Ecited before2024-04-29 · tag F0761 — failed to label and store drugs safely — patternEnsure 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
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, an insulin pen and a vial of Lidocaine were not labeled with an open date and were open and available for use. In addition, narcotics were repackaged into the narcotic cards. Findings included: 1. On 4/24/24 at 8:25 AM, an observation was made of the 100 hallway medication cart with Registered Nurse (RN) 1. A pre-filled pen of Lantus 100 units/milliliter was open and available for use. No open date could be seen on the pen. On 4/24/24 at 8:30 AM, an interview was conducted with RN 1. RN 1 stated the medications that were in the cart were currently being used for the residents. RN 1 stated when an insulin pen was taken out of the medication room the nurses were supposed to label it with an open date. RN 1 stated insulin was good for 30 days after it was opened but could not say how long this insulin pen was good…
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.
- Potential for harm · Dcited before2024-04-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 26 sampled residents, a resident that was dependent on staff and required maximum assistance for bed mobility and toilet use had a brief change performed by one Certified Nursing Assistant (CNA), rolled out of the bed, and received contusions and suffered emotional distress. Resident identifier: 41. Findings included: Resident 41 was admitted to the facility on [DATE] with diagnoses which included fibromyalgia, esophageal varices without bleeding, hepatic encephalopathy, urinary tract infection, alcoholic cirrhoses of the liver with ascites, gastroesophageal reflux disease with esophagititis, essential hypertension, vitamin deficiency, mixed hyperlipidemia, hypothyroidism, gastrointestinal hemorrhage, ileus, anemia, and muscle…
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.
- Potential for harm · Dcited before2024-04-29 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
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 the review, the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 26 sampled residents, a resident that was observed and verbally expressed their pain was not provided pain medication in a timely manner. Resident identifier: 41. Findings included: Resident 41 was admitted to the facility on [DATE] with diagnoses which included fibromyalgia, esophageal varices without bleeding, hepatic encephalopathy, urinary tract infection, alcoholic cirrhoses of the liver with ascites, gastroesophageal reflux disease with esophagititis, essential hypertension, vitamin deficiency, mixed hyperlipidemia, hypothyroidism, gastrointestinal hemorrhage, ileus, anemia, and muscle weakness. Resident 41's medical record was reviewed on 4/24/24. On 4/24/24 at 8:15 AM, during morning…
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.
- Potential for harm · D2024-04-29 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
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 failed to ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, for 1 out of 26 sampled residents, behavioral health services were not provided to a resident who was assessed to need them. Resident identifier: 29. Findings included: Resident 29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included orthopedic aftercare following surgical amputation, type 2 diabetes mellitus with diabetic neuropathy, morbid obesity, osteomyelitis, infection of amputation stump of right lower extremity, methicillin resistant staphylococcus aureus infection, acute respiratory failure with hypoxia, atrial septal defect as current complication following acute myocardial infarction, major depressive disorder, insomnia, congestive 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.
- Potential for harm · D2024-01-03 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 that for 1 of 5 sampled residents that the facility did not notify the facility's physician or resident representative of a significant change in a resident's physical, mental, or psychosocial status. Specifically, the facility did not inform a resident's physician of the resident's change in mental status prior to sending her out for a hemodialysis appointment. Upon arrival to the appointment, the hemodialysis center then sent the resident out to the hospital due to her altered mental status. Resident Identifier: 1 Findings include: Resident 1 was originally admitted [DATE], readmitted [DATE], with diagnoses including, but not limited to: nontraumatic subdural hemorrhage unspecified, other encephalopathy, epilepsy unspecified not intractable without status epilepticus, end stage renal disease, hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side, hypotension unspecified, Alzheimer's disease unspecified, 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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to MONUMENT HEALTH GROUP — 11 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.6 | -0.6 vs chain |
| Health inspection | 2 of 5 | 2.1 | -0.1 vs chain |
| Staffing | 3 of 5 | 2.8 | +0.2 vs chain |
| Quality measures | 4 of 5 | 4.7 | -0.7 vs chain |
The other 10 homes this chain runs (chain average 2.6★, 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 / manager | Type | Role | Since |
|---|---|---|---|
| MURRAY, BRIAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2020 |
| GUNNISON VALLEY HOSPITAL | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/28/2025 |
| HEALTH GROUP MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| MONUMENT HEALTH GROUP LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| CLAWSON, TRAVIS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| FRAGOSO, LINDSAY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| GALINDO, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| MARRIOTT, STEPHEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| MERKLEY, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/16/2026 |
| ROBERTSON, BRETT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| SAMUELIAN, SPENCER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| SANTIBANEZ, JORGE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| SEASTRAND, JASON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| WEST, CHRISTIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| WEST, SHAY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| MONUMENT HEALTH PROPERTIES LLC | Organization | ADP OF THE SNF | since 02/07/2025 |
| MONUMENT REAL ESTATE NORTH BOUNTIFUL LLC | Organization | ADP OF THE SNF | since 02/07/2025 |
CMS files one row per role, so the 33 rows in the source record cover these 17 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.
5 organizational owners 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.
This home reported $4.7M paid to related parties — landlords or management companies under common ownership — equal to about 56% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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
Straight from this home’s Medicare cost report (CMS, FY2024). 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
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.
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 2026-09-01 — CMS provider number 465156. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-25, 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.