Monument Healthcare Brigham City
775 North 200 East, Brigham City, UT 84302 · For profit - Limited Liability company · 84 certified beds · (435) 723-7777 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS has flagged it for abuse
- it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,166 in federal fines (most recent 2025-12-03)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor
- about 55% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 4 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
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 5 of 5 |
| Long-stay residentspeople who live here | 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 held steady at 3 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 | 8.1% | 11.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.1% | 3.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.9% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 24.8% | 16.5% | 6.5% | worse 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 | 0.9% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 12.6% | 15.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 44.6% | 25.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.1% | 3.9% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.6% | 21.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 21.2% | 14.2% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 0.9% | 1.4% | better |
‡ 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.
56.8% 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 37 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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 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
| 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 | 56.8%CMS range 46.2–69.3 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.9%CMS range 6.5–15.9 | 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 | not 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 discharge | not 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 discharge | not 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 identified | not 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 next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not 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 discharge | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not 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 SNFs | 1.04 | 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
No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.
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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
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.
21 citations, most serious first. The 13 most serious are shown; the remaining 8 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-04-16 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, for 1 out of 27 sampled residents, staff were unable to locate a resident for a period of time. There was an area of the facility that was locked an unaccessable to staff. There was a facility staff member in the locked area that the resident was observed to exit from. The resident made statements that the staff member engaged in sexual actions with her. In addition, the staff member had been talked to about not remaining in the facility after dinner time. This example was cited at Immediate Jeopardy. Resident identifiers: 4, 6, 12, 23, 28, 31, 36, 90 and 141. Findings included: Notice: On 4/11/24 at 12:15 PM, Immediate Jeopardy (IJ) was identified when the facility failed to implement Centers for Medicare and Medicaid Services recommended practices to prevent various forms of abuse. Notice of the IJ was given…
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 before2025-12-03 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 out of 13 sampled residents, the facility did not ensure residents had a right to be free from neglect. Specifically, a resident was left in a wet brief for an extended period of time and sustained a rash and excoriation to the groin. This resulted in a finding of harm for the resident. Resident identifier: 9.Findings included: Resident 9 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, unspecified urinary incontinence, mild cognitive impairment of uncertain or unknown etiology, and cognitive communication deficit.Resident 9's medical record was reviewed on 12/3/25.On 3/13/25 at 10:00 PM, a progress note documented, Oncoming aides rounded on resident and discovered excoriated peri-area [perineum] with a split open area at the left waist approx [approximately] 3 inches long. There is also an area on her left shoulder that appears to be a rash approx 4x 4 without any open areas.…
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 before2020-02-20 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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, it was determined that for 1 of 24 sample residents, the facility did not ensure that residents' drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, a resident receiving anti-coagulation medication did not receive timely monitoring and was subsequently hospitalized . In addition, a resident who was supposed to receive a taper of medication did not receive this in a timely manner. Resident identifier: 88. This deficiency was cited at past non-compliance. The facility, upon determining that a lab had been missed and a resident was hospitalized , determined the cause of the missed lab. They put a Four Step action plan into place, including audits, staff education,…
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 · D2026-07-01 · 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 review, for 1 of 20 sampled residents, the facility did not ensure that pain management services were provided in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals. Specifically, a nurse failed to timely assess and administer a prescribed as-needed (PRN) opioid pain medication to a resident experiencing pain after repeated requests from the resident and alerts from multiple certified nursing assistants (CNAs). The resident experienced pain, which was described by the resident as agony, for more than four hours. Resident identifier: 33. Findings included:Resident 33 was admitted to the facility on [DATE] with diagnoses which included: Muscular Dystrophy, Unspecified; Other Specified Disorders of Teeth and Supporting Structures; Major Depressive Disorder, Recurrent, Moderate; Unspecified Dementia, Moderate, Without Behavioral Disturbance; and Personality Disorder, Unspecified. On 6/29/26 at 9:28 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 · F2024-04-16 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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, interview, and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dish machine washing temperature was not manufacture required temperature and there were no sanitizer strips available to test the solution. Findings included: 1. On 4/8/24 at 9:03 AM, an initial tour of the kitchen was conducted. The following observation was made of the dish machine [Note: All temperatures were in degrees Fahrenheit.] a. The washing temperature was 110 and the rinse temperature was 120. There were 11 plates, five cups, one dessert dish, and a lid that were in the dish machine. An observation was made of the Dietary Manager (DM) replacing the dishes with the clean dishes. b. The washing temperature was 110 and the rinse temperature was 120. The dish machine basket had seven trays in it and were replaced with clean dishes. An interview was immediately conducted with the DM. The DM stated the dish machine was between 100 and 200 degrees and was usually over 140. The DM…
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 · E2024-04-16 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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 provide a clean, comfortable, homelike environment. Specifically, there were odors throughout the facility. Findings included: On 4/8/24 at 8:57 AM, an observation was made in the hallway between room [ROOM NUMBER] to room [ROOM NUMBER]. There was a strong urine odor. On 4/8/24 from 11:45 AM to 11:52 AM, an observation was made in the hallway between room [ROOM NUMBER] to room [ROOM NUMBER]. There was a strong urine odor. On 4/9/24 at 9:08 AM, an observation was made in the hallway between room [ROOM NUMBER] to room [ROOM NUMBER]. There was a strong urine, bowel movement, and body odor through the hallway. On 4/9/24 at 11:54 AM, an observation was made in the hallway outside room [ROOM NUMBER] and into the dining room. There was a strong urine odor. On 4/9/24 at 12:04 PM, an observation was made in the dining room and the hallway between room [ROOM NUMBER] to room [ROOM NUMBER]. There was a strong urine odor. On 4/10/24 at 7:40 AM, an observation was made…
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 · E2024-04-16 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, for 4 out of 27 sampled resident, residents complained of food quality and a test tray was bland. Resident identifiers: 4, 9, 15, and 27. Findings included: On 4/8/24 at 10:44 AM, an interview was conducted with resident 27. Resident 27 stated the food was unappealing and unappetizing. On 4/8/24 at 9:32 AM, an interview was conducted with resident 15. Resident 15 stated she was sensitive to spices and strong flavors. Resident 15 stated lately the food had been pretty spicy. Resident 15 stated most foods had peppers of some kind added to them. On 4/8/24 at 10:24 AM, an interview was conducted with resident 9. Resident 9 stated the food was not good and there were no substitutes. On 4/8/24 at 10:49 AM, an interview was conducted with resident 4. Resident 4 stated we need better food. Resident 4 stated she was not allowed to have more than four ounces of juice per day. On 4/9/24 at 12:24 PM, an observation was made…
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 · E2024-04-16 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to provide a suitable, nourishing alternate meals and snacks for residents wanting to eat at non-traditional times, or outside of scheduled meal service times. Specifically, for 5 out of 27 sampled residents, residents were only offered saltine crackers for snacks. Resident identifiers: 3, 4, 6, 31, and 141. Findings included: On 4/8/24 at 9:00 AM and 2:30 PM, an observation was made of a container at the south nurses station. There were saltine crackers in the container. On 4/8/24 at 9:15 AM and 2:35 PM, an observation was made of a container at the north nurses station. There were saltine cracker in the container and one of the saltine crackers was open to air. On 4/9/24 at 9:30 AM, an observation was made of the north nurses station. There were saltine crackers in a container on the counter and one of the saltine crackers was open to air. On 4/9/24 at 2:00 PM and 4:00 PM, an observation was made at the south nurses station. There were saltine crackers in a container on the counter. On 4/10/24 at 12:33 PM, an observation was…
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 · D2024-04-16 · 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
Based on interview and record review, the facility did not develop and implement written polices and procedures that prohibited and prevented abuse, neglect, and exploitation of residents. Specifically, a staff member was not connected to the facility through the Direct Access Clearance System (DACS). Findings included: Physical Therapy Assistant (PTA) 1's employee file was reviewed on 4/10/24. The file revealed an offer letter for another facility. There was no information regarding PTA 1 being employed with the facility being surveyed. The information provided was from a contract rehabilitation company. On 4/9/24 at 4:17 PM, an interview was conducted with the Administrator. The Administrator stated prior to a staff member working with residents a background screening was completed. The Administrator stated PTA 1 had a background screening completed and there were no problems. On 4/11/24 at 9:08 AM, an interview was conducted with the Background Processing Manager (BPM) at the State Survey Agency. The BPM checked PTA 1 in the DACS. The BPM stated that PTA 1 was eligible for work…
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 · D2024-04-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs. Specifically, for 1 out of 27 sampled residents, a resident did not have an intervention implemented from his care plan which resulted in multiple falls, a skin tear, and hip pain. Resident Identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, surgical amputation, diabetes mellitus, hyperlipidemia, hypertension, coronary artery disease, and chronic pain syndrome. Resident 9's medical record was reviewed on 4/9/24. A review of Resident 9's care plan initiated on 2/20/24, showed that the resident is at risk for falls and has had an actual fall r/t [related to] gait/balance problems. Resident 9's care plan was revised on 3/6/24, with interventions to include a bed change 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 · D2024-04-16 · 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 did not ensure that the resident environment remains free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 27 sampled residents, a resident did not have an assistance device to prevent falls which resulted in multiple falls. Resident Identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, surgical amputation, diabetes mellitus, hyperlipidemia, hypertension, coronary artery disease, and chronic pain syndrome. Resident 9's medical record was reviewed on 4/9/24. A review of Resident 9's care plan initiated on 2/20/24, showed that the resident is at risk for falls and has had an actual fall r/t [related to] gait/balance problems. Resident 9's care plan was revised on 3/6/24, with interventions to include a bed change to a bariatric bed. On 3/6/24 at 6:33 AM, a Nursing…
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 · E2022-06-27 · tag F0636 — patternAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 conduct comprehensive assessments of residents in accordance with the timeframe's specified. Specifically, for 3 out of 31 sampled residents, comprehensive assessments of residents were not completed at least once every 12 months. Resident identifiers: 13, 90, and 91. Findings included: 1. Resident 13 was admitted to the facility on [DATE] with diagnoses which include polyosteoarthritis, contracture of muscle, anoxic brain damage, muscle wasting and atrophy, fistula of stomach and duodenum, and adult failure to thrive. On 6/23/22, resident 13's medical record was reviewed. Resident 13's annual Minimum Data Set (MDS) assessment was reviewed, and it was revealed that the target date for completion of the most recent annual MDS assessment was 4/7/22. The annual MDS assessment was not completed, and the status was marked as In Progress. 2. Resident 91 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses…
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 · E2022-06-27 · tag F0638 — patternAssure that each resident’s assessment is updated at least once every 3 months.
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 assess residents using the quarterly review instrument specified by the State and approved by Centers for Medicare & Medicaid Services not less frequently than once every 3 months. Specifically, for 13 out of 31 sampled residents, quarterly Minimum Data Set (MDS) assessments were not completed every 3 months. In addition, quarterly MDS assessments were not completed no later than 14 days after the assessment reference date (ARD). Resident identifiers: 1, 2, 3, 4, 6, 9, 13, 16, 26, 30, 89, 90, and 142. Findings included: 1. Resident 89 was admitted to the facility on [DATE] with diagnoses which included acute osteomyelitis, iron deficiency, rheumatoid arthritis, essential hypertension, major depressive disorder, and osteoarthritis. On 6/23/22, resident 89's medical record was reviewed. Resident 89's quarterly MDS assessment was reviewed, and it was revealed that the ARD target date for completion of the quarterly MDS assessment was…
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 8 citations
- Potential for harm · E2022-06-27 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
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, it was determined, the facility did not encode discharge Minimum Data Set (MDS) assessment data within 7 days after a facility completes a resident's assessment. Specifically, for 3 out of 31 sampled residents, discharge assessments were not completed and transmitted. Resident identifiers: 5, 11, and 14. Findings included: 1. Resident 5 was admitted to the facility on [DATE] with diagnoses which included Guillain-Barre syndrome, muscle weakness, type 2 diabetes mellitus, cognitive communication deficit, and unsteadiness on feet. On 6/23/22, resident 5's medical record was reviewed. Resident 5's face sheet was reviewed, and revealed that resident 5 was discharged from the facility on 5/28/22. Resident 5's discharge Minimum Data Set (MDS) assessment was reviewed, and it was revealed that the target date for the completion of the discharge MDS assessment was 5/28/22. The discharge MDS assessment was not completed, and the status was marked as In Progress. 2. Resident 11 was admitted…
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 · D2022-06-27 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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 comprehensively assess a resident within 14 days after determining, or should have determined, that there has been a significant change in the resident's physical or mental condition. Specifically, for 1 out of 31 sampled residents, a resident that was discharged from Hospice services did not have a significant change Minimum Data Set (MDS) assessment completed. Resident identifier: 2. Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, type 2 diabetes mellitus without complications, chronic pain, major depressive disorder, long term use of opiate analgesic, urinary tract infection, encounter for palliative care, and mild protein-calorie malnutrition. Resident 2's medical record was reviewed on 6/22/22. A physician's order for Hospice services was discontinued on 6/2/22. Resident 2's significant change MDS assessment was reviewed, and it was revealed that the target…
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 · D2022-06-27 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 assessments did not accurately reflect the resident's status. Specifically, for 1 out of 31 sampled residents, a resident's discharge Minimum Data Set (MDS) assessment was coded incorrectly by indicating that a resident was discharged to a hospital when the resident was actually discharged home. Resident Identifier: 40. Findings Included: Resident 40 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, difficulty in walking, muscle weakness, and arthritis. On 6/23/22, resident 40's medical record was reviewed, and it was revealed that the discharge MDS assessment indicated that resident 40 had been discharged to an acute hospital. A progress note dated 4/16/22 at 9:13 AM, was reviewed. The progress note documented, Discharge Summary: Pt [Patient] admitted to facility on 4-12-22. Pt's stay was largely uneventful and pt is discharging to home today. On 6/23/22 at 10:40 AM, an interview with the Social…
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 before2022-06-27 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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, it was determined, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 31 sampled residents, a resident's medications to treat high blood pressure were held without physician ordered parameters. Resident identifier: 30. Findings included: Resident 30 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, cervical disc disorder with myelopathy, speech disturbances, mild protein-calorie malnutrition, neuromuscular dysfunction of bladder, left knee contracture, major depressive disorder, generalized anxiety disorder, type 2 diabetes mellitus, essential hypertension,…
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 · E2020-02-20 · tag F0755 — failed to provide safe pharmacy services — patternProvide 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 6 of 24 sample residents, that the facility did not provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. Specifically, six residents did not have medications available for administration. Resident identifiers: 7, 8, 9, 21, 31 and 33. Findings include: 1. Resident 9 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular accident, hypertension, vascular dementia, congestive heart failure, aortic valve insufficiency, type 2 diabetes mellitus and anxiety. On 2/19/20 resident 9's medical record was reviewed. Nursing progress notes revealed the following entries: a. 12/1/2019 19:02 (7:02 PM), Orders - Administration Note Note Text: Atorvastatin Calcium Tablet 20 MG (milligrams) Give 1 tablet by mouth at bedtime for Hx (history) of stroke on reorder. b. 12/6/2019 18:45 (6:45 PM), Orders -…
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 · E2020-02-20 · 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 2. Resident 19 was admitted to the facility on [DATE] with diagnoses that included epilepsy, dysphagia, atherosclerosis, dysuria, cerebral palsy, and thyroid atrophy. Resident 19's medical record was reviewed on 2/18/20. Resident 19's physician orders revealed that resident 19 was to have the following labs drawn: a. On 10/2/19, a Basic Metabolic Panel (BMP), and Complete Blood Count (CBC) to be done every 6 months, beginning in October 2019. b. On 10/2/19, a Thyroid Stimulating Hormone (TSH) to be done every October, beginning in October 2019. Review of resident 19's medical record did not reveal the laboratory results for the above lab orders. On 2/20/20 at 9:30 AM, an interview was conducted with the facility Administrator (ADM). The ADM provided the laboratory results for resident 19's BMP, CBC and TSH, and showed that the labs were completed in October 2019 as ordered, but were not in resident 19's medical record. The ADM confirmed that the laboratory results should have been in resident 19's medical…
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 · D2020-02-20 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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 of 24 sample residents, that the facility did not notify a representative of the Office of the State Long-Term Care Ombudsman of the transfer or discharge and the reasons for the move in writing. Specifically, when residents were discharged to the hospital, the facility Ombudsman was not notified. Resident identifiers: 25 and 35. Findings include: 1. Resident 35 was admitted to the facility on [DATE] with diagnoses which included coronary artery disease, heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease, anxiety and depression. Resident 35 passed away at the facility on 8/18/19. Resident 35 had been hospitalized for a change in condition with his respiratory system and pneumonia prior to passing away in the facility. That hospitalization had not been called into the State Long Term Care Ombudsman office. 2. Resident 25 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses with included nausea with…
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 · D2020-02-20 · tag F0770 — failed to provide lab services — isolatedProvide 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 it was determined, for 2 of 24 sampled residents, that the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, the facility physician ordered a Valproic Acid level and a Urinalysis (UA) for two residents and they were not obtained. Resident identifiers: 5 and 19. Findings include: 1. Resident 5 was admitted to the facility on [DATE] with diagnoses which included hypertensive heart disease, left ventricular failure, diabetes mellitus type 2, major depressive disorder, persistent mood disorder, anxiety disorder, malignant neoplasm of the left breast, and pain. On 2/19/20 resident 5's medical records were reviewed. Review of resident 5's pharmacy recommendation on 4/15/19 documented to check a valproic acid level now and again in 6 months. On 4/17/19, the physician accepted the pharmacist's recommendation and ordered to implement as written by the pharmacist. Review of the laboratory results in resident 5's medical records did…
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
$10,166 in federal fines across 1 penalty.
- $10,166 — penalty dated 2025-12-03
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 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 | 2.8 | -0.8 vs chain |
| Health inspection | 1 of 5 | 2.2 | -1.2 vs chain |
| Staffing | 1 of 5 | 2.8 | -1.8 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 10 homes this chain runs (chain average 2.8★, 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 |
|---|---|---|---|
| GUNNISON VALLEY HOSPITAL | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/04/2025 |
| MURRAY, BRIAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2018 |
| 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 |
| ESPINOSA, STEPHANIE | 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 |
| MARRIOTT, STEPHEN | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 02/07/2025 |
| NIXON, TYLER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| OSTERMILLER, MERCEDES | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| 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 |
| SEASTRAND, JASON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| SIMS, BRADEN | 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 |
CMS files one row per role, so the 31 rows in the source record cover these 15 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.
3 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.
About 84% 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 $2.9M paid to related parties — landlords or management companies under common ownership — equal to about 55% 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 2026-08-01 — CMS provider number 465093. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-04-16, 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.