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Cedar Health and Rehabilitation

411 West 1325 North, Cedar City, UT 84721 · For profit - Corporation · 120 certified beds · (435) 586-6481 Medicare & Medicaid certified

Call the home — (435) 586-6481 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent Jun 20251 actual-harm citation
Insights

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

In its favor
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (20) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)

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.

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

Worth a closer look. This home's staffing and quality-measure ratings run 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, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1251 Northfield Rd Ste 301 · (435) 865-7227 · Call to confirm hours
Pharmacy
108 W 1325 N · (435) 867-0800 · Call to confirm hours
Grocery
1111 N Main St · (435) 233-8480 · Call to confirm hours
Park
660 W 1045 N · (435) 865-9223 · Typically dawn to dusk

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 4 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.3%11.3%15.4%better
Long-stay residents who lose too much weight10.6%3.4%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection0.0%1.8%2.0%better
Long-stay residents with depressive symptoms16.0%16.5%6.5%typical for the state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.7%2.5%3.3%better
Long-stay residents whose ability to walk worsened20.9%15.1%16.1%worse
Long-stay residents on antianxiety or hypnotic medication30.4%25.3%18.9%worse
Long-stay residents given the seasonal flu vaccine96.6%98.0%95.3%typical
Long-stay residents with pressure ulcers0.8%3.9%4.7%better
Long-stay residents with worsening bladder/bowel control19.5%21.5%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table9.6%14.2%17.1%better
Short-stay residents who newly got an antipsychotic medication1.5%0.9%1.4%typical
Short-stay residents given the seasonal flu vaccine80.5%91.0%79.4%typical
Short-stay residents rehospitalized after admission22.1%16.5%22.6%typical
Short-stay residents with an outpatient ER visit13.3%11.6%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.781.251.67typical
Long-stay outpatient ER visits per 1,000 resident days1.461.431.80better

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.

52.1% 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 90 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

52.1%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
66.0%U.S. median 56.6%
Met the expected recovery
0.53U.S. median 0.31
Therapy hours / resident / day
0.28hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 66.0% 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 47 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 0.53 therapist hours per resident per day in 2026Q1 — more than 83% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF52.1%CMS range 42.8–63.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 7.0–13.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge66.0%56.6%Oct 2024–Sep 2025CMS 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 discharge74.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge51.1%50.0%Oct 2024–Sep 2025CMS 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 identified97.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting97.3%100.0%Oct 2024–Sep 2025CMS 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.1%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.7%CMS range 2.4–12.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.001.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.75
RN hours/ resident / day
0.80
LPN hours/ resident / day
2.42
Aide hours/ resident / day
3.97
Total nurse hours/ resident / day
0.40
RN hoursweekends
39.5%
Total nursing turnover
30.0%
RN turnover

How full it usually is: this home is certified for 120 beds and averages 71.9 residents a day — about 60% occupied, or roughly 48 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 3.97 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.75 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.42 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 3.55 hrs/resident/day on weekends vs 4.14 on weekdays — 14% thinner on weekends. RN hours go from 0.89 to 0.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 40% is about the same as the national median of 45%.

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

Inspection trend

10
deficiencies at the latest standard inspection (2025-06-26)
8
at the previous standard inspection (2023-07-13)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

20 citations, most serious first. The 11 most serious are shown; the remaining 9 are one tap away and print in full.

  • Actual harm · G2025-06-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined for 5 out of 41 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible; and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, 5 residents had multiple falls without continued attempts at interventions to prevent additional falls. Additionally, one resident had repeated accidents while operating his motorized wheelchair and had been assessed as not safe to operate the motorized wheelchair. Resident identifiers: 1, 39, 43, 53, and 62.Findings included:1. Resident 53 was admitted to the facility on [DATE] with diagnoses which included palliative care, anxiety disorder, and Alzheimer's disease. On 6/23/25 at 8:01 AM, an observation was made of resident 53. Resident 53 was wandering in the dining room and hallway with one non-slip grip sock on her foot and one on her hand. Resident 53's medical record 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-26 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, for 6 of 41 sampled residents, 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 that are identified. Specifically, after residents sustained falls there were no interventions or the interventions were reused and a resident did not have hospice services care planned. Resident identifiers: 1, 39, 43, 53, 62 and 64.Findings include: 1. Resident 53 was admitted to the facility on [DATE] with diagnoses which included palliative care, anxiety disorder, and Alzheimer's disease. On 6/23/25 at 8:01 AM, an observation was made of resident 53. Resident 53 was wandering in the dining room and hallway with one non-slip grip sock on her foot and one on her hand. Resident 53's medical record was reviewed 6/22/25 through 6/26/25. An admission Minimum Data Assessment (MDS) dated [DATE] revealed 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-06-26 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
    Ensure 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, for 5 of 41 residents, the facility did not provide food prepared by methods that conserve flavor and appearance or provide food and drink that was palatable, attractive, and at an appetizing temperature. Specifically, residents complained of cold food and too much processed food. Resident Identifiers: 6, 9, 15, 33, and 75.Findings Included:On 6/22/25 at 2:17 PM, an interview was conducted with resident 33 who stated he had received a cold hamburger with beef that tasted like fake meat. Resident 33 stated it tasted like it had been mixed with something. Resident 33 stated he had provided feedback to the kitchen staff, but it did not seem to help. Resident 33 stated he would eat lunch, but would not eat breakfast or dinner. Resident 33 stated if he wanted something to eat he could ask for a quesadilla. On 6/22/25 at 3:18 PM, an interview was conducted with resident 6. Resident 6 stated that the food was not that great. Resident 6 stated that the food was not always served warm when the food items should be warm. On 6/23/25 at 9:33…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-06-26 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer and the walk-in refrigerator were open to the air.Findings included:On 6/22/25 at 1:03 PM, an initial walk-through was conducted in the kitchen. In the walk-in freezer, a package of diced chicken was open to air and a box of ground beef patties were open to air.On 6/25/25 at 1:31 PM, a second walk-through was conducted in the kitchen. In the walk-in refrigerator, a box of raw bacon with a written date of 6/16/25 was open to air. [Note: The box stated store at 0 degrees, keep frozen or below.]On 6/25/25 at 2:06 PM, an interview was conducted with the Dietary Manager (DM). The DM stated the Consultant Dietitian came to the facility every 2 weeks. The DM stated while at the facility, the consultant dietitian completed a kitchen audit that included sanitation, inspection of the refrigerators and freezers for expired food and food safety issues. The DM stated she received an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-26 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 41 sampled residents, the facility failed to promote and facilitate resident self-determination through support of resident choice, including the right to choose activities and schedules, and to make choices about aspects of his or her life in the facility that are significant to the resident. Specifically, two residents who were assessed as independent smokers were not allowed to smoke at night. Resident identifiers: 6 and 15.Findings included:1. Resident 15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute and chronic respiratory failure, cerebral infarction, bipolar disorder, hypertension, anxiety disorder, and major depressive disorder.On 6/23/25 at 9:17 AM, an observation of resident 15 was made. Resident 15 was outside in the smoking area, no staff or other residents were present. Resident 15 was vaping and was not wearing oxygen.Resident 15's medical record was reviewed 6/22/25 through…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-26 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately 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, for 1 of 41 sampled residents, that the facility did not consult with the resident's physician when there was a significant change in the resident physical status, or a need to alter treatment. Specifically, the resident reported breaking his tooth after sustaining a fall and the injury was not reported to the physician. Resident identifier: 39.Findings included:Resident 39 was admitted to the facility on [DATE] with diagnoses which consisted of traumatic brain injury, atrial fibrillation, hypertension, chronic kidney disease, esophagitis with bleeding, and chronic pain. On 6/22/25 at 2:03 PM, an interview was conducted with resident 39. Resident 39 stated that he fell and knocked his tooth out during the fall. Resident 39 stated that he was sleeping prior to the fall. Resident 39's medical records were reviewed.On 7/8/24 at 4:50 PM, resident 39's progress note documented, Resident brought part of his tooth in a container to nurse this morning. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-26 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 out of 41 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events resulted in serious bodily injury to the administrator, State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, a resident reported a broken tooth to the staff and the SSA and APS were not notified of the injury of unknown source. Resident identifier: 39.Findings included:Resident 39 was admitted to the facility on [DATE] with diagnoses which consisted of traumatic brain injury, atrial fibrillation, hypertension, chronic kidney disease, esophagitis with bleeding, and chronic pain. On 6/22/25 at 2:03 PM, an interview was conducted with resident 39. Resident 39 stated that he fell and knocked his tooth out during the fall. Resident 39 stated that he 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-26 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined, for 1 out of 41 sampled residents, that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, a resident did not receive her morning dose of Metoprolol due to the medication being out of stock. Resident identifier 37.Findings included:Resident 37 was admitted to the facility on [DATE] with diagnoses which consisted of essential hypertension and chronic kidney disease stage 3.On 6/24/25 at approximately 8:00 AM, an observation was made of Licensed Practical Nurse (LPN) 1 during morning medication administration for resident 37. LPN 1 did not administer resident 37's scheduled Metoprolol due to the medication not being available.Resident 37's medical records were reviewed.On 11/26/24, resident 37 had an order initiated for Metoprolol Tartrate Oral Tablet 50 milligram (mg), give 1 tablet by mouth two times a day for hypertension. The order documented that the medication was scheduled to be administered during…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-26 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    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 it was determined, for 1 of 4 residents sampled, that the facility did not ensure that medication error rates were not 5 percent or greater. Specifically, observations were made of 4 medication errors out of 32 medication opportunities that resulted in a medication error rate of 12.5%. A resident's Metoprolol administration was missed due to the medication not being available from the pharmacy, and a Farxiga, Oxycodone, and Potassium Citrate Extended Release tablets were administered crushed and the manufacturer recommended to take the medications whole. Resident identifier: 37.Findings included:Resident 37 was admitted to the facility on [DATE] with diagnoses which consisted of sarcoidosis, systemic inflammatory response syndrome, anxiety disorder, obstructive sleep apnea, monoclonal gammopathy, type 2 diabetes mellitus, cognitive communication deficit, dysphagia, essential hypertension, chronic kidney disease stage 3, and low back pain.On 6/24/25 at approximately 8:00 AM, an…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-26 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment or to help prevent the development and transmission of communicable diseases and infections. Specifically, during hallway meal pass, CNAs (Certified Nursing Assistant) did not sanitize their hands between delivery of meal trays to residents dining in their rooms. Additionally, desserts were not covered on the trays delivered to resident rooms.Findings included:On 6/24/25 at 1:13 PM, CNA 5 delivered a tray to room [ROOM NUMBER]. The resident refused the tray so the tray was returned to the cart. CNA 5 did not sanitize her hands after returning the cart. On 6/24/25 at 1:14 PM, CNA 5 delivered a tray to room [ROOM NUMBER]. The dessert was not covered on the tray. CNA 5 obtained another tray from the cart without sanitizing her hands and delivered a second tray to room [ROOM NUMBER]. The dessert was not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-07-13 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined for 6 of 20 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA). Specifically, entity reports of multiple abuse allegations were not submitted to the SSA in a timely manner. Resident identifiers: 9, 25, 43, 46, 124 and 225. Findings include: 1. Resident 225 was admitted to the facility on [DATE] with diagnoses which included acute diastolic congestive heart failure, type II diabetes, athreosclerotic heart disease, chronic pain syndrome, anxiety, gout, muscle weakness and dysphagia. Resident 225's medical record was reviewed on 7/11/23. A nursing progress note dated 7/6/23 at 1:39 PM documented, Resident had C/O [complained of] pain to Left wrist. PA [Physician Assistant] evaluated resident and orders given to obtain L [left]…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 9 citations
  • Potential for harm · E2023-07-13 · tag F0610 — failed to investigate and act on abuse reports — pattern
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined for 6 of 30 sample residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to have evidence that all alleged violations were thoroughly investigated and were not reported to the State Survey Agency (SSA) within 5 days of the incident. Specifically, the facility did not thoroughly investigate multiple falls that resulted in fractures. Resident Identifiers: 9, 15, 25, 43, 46 and 124. Findings included: 1. Resident 9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included insomnia, type 2 diabetes, fracture of right femur, repeated falls and muscle weakness. On 4/22/23, a Quarterly Minimum Data Set (MDS) documented resident 9 had a BIMS of 10 which indicated resident 9 was moderately cognitively impaired. Resident 9's functional status documented they required a one person limited assisted with transfers. Resident 9's progress notes, incident reports and facility…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-13 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    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 30 sampled residents, that the facility did not coordinate assessments with the pre-admission screening and resident review (PASARR) program. Including referring all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Specifically, after a resident was diagnosed with a mental illness and there was no referral for a level II. Resident identifier: 58. Findings include: Resident 58 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease, bipolar disorder, major depressive disorder, cognitive communication deficit, altered mental status and osteoarthritis of the shoulder. On 7/11/23, the medical record of resident 58 was reviewed. A review of resident 58's Pre-admission screening Application/Resident Review (PASRR) dated 10/30/21 revealed there was no serious…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-13 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 1 out of 30 sampled residents, that the facility did not provide the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless circumstances of the individual's clinical condition demonstrated that such diminution was unavoidable. Specifically, a resident was not provided assistance with ensuring a resident's shoes were cleaned before putting resident into bed. Resident identifier: 43. Findings include: Resident 43 was admitted to the facility on [DATE] with diagnoses which included non-traumatic chronic subdural hemorrhage, nicotine dependence, altered mental status, hypertension, transient ischemic attack (TIA), and vascular dementia. On 7/10/23 at 2:55 PM, an observation was made of resident 43's shoes. Resident 43 was laying in bed with shoes on. There was a brownish/orange substance on his shoes. Resident 43's white shoes were observed to have black substance on them.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 30 sampled residents, that the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, a dependent resident was not provided nail care. Resident identifier: 51. Findings include: Resident 51 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, peripheral vascular disease, hemiplegia, dysphagia, asphia, and muscle wasting atrophy. On 7/10/23 at 2:20 PM, an observation was made of resident 51. Resident 51 was observed with long fingernails with a brown and black substance under her nails. Resident 51 was observed to have pink nail polish on one hand and red nail polish on the other hand. Resident 51's nail polish was chipped. Resident 51's medical record was reviewed 7/10/23 through 7/13/23.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-13 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that 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, a vial of insulin and insulin pens were open and available for use without an expiration date and without resident identifier information. Findings included: 1. On [DATE] at 7:40 AM, an observation was made of the 300 hallway medication cart with Registered Nurse (RN) 1, the following medications were located inside: a. A bottle of Levemir (insulin detemir) 100 units/ml (milliliter) was opened and available for use and labeled with an open date of [DATE]. b. A pre-filled pen of Levemir (insulin detemir) 100 units/ml was opened and available for use and not labeled with an open date. c. A pre-filled pen of Novolog 100 units/ml was opened and available for use and labeled with an open date of [DATE]. d. A pre-filled pen…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-07-13 · tag F0779 — isolated
    Keep signed and dated reports of x-rays and other diagnostic services in the residents 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 it was determined, for 1 of 30 sampled residents, that the facility did not file in the resident's clinical record signed and dated reports of radiological services. Specifically, a resident's x-ray was not located in the medical record. Resident identifier: 43. Findings include: Resident 43 was admitted to the facility on [DATE] with diagnoses which included non-traumatic chronic subdural hemorrhage, nicotine dependence, altered mental status, hypertension, transient ischemic attack, and vascular dementia. Resident 43's medical record was reviewed 7/10/23 through 7/13/23. A progress note dated 2/21/23 at 10:07 PM revealed Nurse was called to residents room by another resident. Stating that she heard someone fall and yell for help. Resident was laying on the floor next to his bed with his wheelchair on top of him. Resident was helped into bed with bed alarm in place and turned on. Resident has a small cut to the right eyebrow. Cut was cleaned with saline and steri-strips were…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-07-13 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there was a brown substance in the dish machine, there were unclean areas in the kitchen and unlabeled food items. Findings include: 1. On 7/10/23 at 1:47 PM, an initial tour of the kitchen was conducted. The following observations were made: a. There were egg patties open to air in the freezer. b. There was french bread dough open to air in the freezer. c. There was rice open to air in the dry food storage area. d. There was food splatter on the ceiling in the dish machine area. 2. On 7/13/23 at 8:47 AM, a follow-up kitchen tour was conducted. The following observations were made: a. There was food on the floor behind the table with the juice machine on it. b. There was debris, margarine packets and 2 plastic item under the pots and pans shelf. c. The inside of the oven was soiled on the doors and on the bottom. The outside handles had substance on them. d. A table with the steamer on it…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-08-19 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility did not develop and implement a comprehensive person-centered care plan for 3 of 32 sample residents, consistent with the resident right that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Specifically, fall care plans were not updated and/or implemented as required. Resident identifiers: 19, 31, and 41. Findings include: 1. Resident 19 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm, idiopathic aseptic necrosis of unspecified toes, iron deficiency anemia, and major depressive disorder. On 8/18/21 at 9:45 AM, resident 19 was observed in her room lying in bed. There was no floor mat observed on either side of her bed and the call light was hanging on the south wall at the head of resident 19's bed, out of her reach. On 8/19/21 9:19 AM, resident 19 was observed in her room lying in…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-08-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined that the facility did not maintain, for 1 of 32 sample residents, acceptable parameters hydration status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible. Specifically, one resident did not receive the required amount of water through a feeding tube. Resident identifier: 41. Findings included: Resident 41 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, atrial fibrillation, anxiety and depression, COPD, heart failure, and decreased vision. After admission, resident 41 was diagnosed with pneumonitis due to inhalation of food and vomit, muscle wasting, kidney disease and dysphagia. On 8/17/21 at 10:38 AM, resident 41 was observed lifting his legs and arms in bed. Resident 41 was observed holding a book and stated that he wanted to get out of bed. Resident 41 had a bag of Fibersource 1.2 kcal/mL (1000 calories per…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 2 of 53.2-1.2 vs chain
Health inspection 2 of 52.8-0.8 vs chain
Staffing 4 of 52.7+1.3 vs chain
Quality measures 4 of 54.4-0.4 vs chain
The other 341 homes this chain runs (chain average 3.2★, per CMS)
1 of 5Aspen Health And WellnessOverland Park, KS 1 of 5Bennett Hills Rehabilitation and Care CenterGooding, ID 1 of 5Broadway By The SeaLong Beach, CA 1 of 5Chatsworth Park Health Care CenterChatsworth, CA 1 of 5Clarion Wellness and Rehabilitation CenterClarion, IA 1 of 5Colonial Manor of RandolphRandolph, NE 1 of 5Durango Health And RehabilitationDurango, CO 1 of 5Fort Dodge Health and RehabilitationFort Dodge, IA 1 of 5Greater Southside Health and RehabilitationDes Moines, IA 1 of 5Hearthstone Health And RehabilitationSparks, NV 1 of 5Heritage Gardens Rehabilitation and HealthcareCarrollton, TX 1 of 5Hillcrest Health Care CenterHawarden, IA 1 of 5Lake Village Nursing And Rehabilitation CenterLewisville, TX 1 of 5Lakeside Rehabilitation and Care CenterCoeur d'Alene, ID 1 of 5Legend Oaks Healthcare And Rehabilitation - NorthAustin, TX 1 of 5Legend Oaks Healthcare And Rehabilitation - WaxahaWaxahachie, TX 1 of 5Legend Oaks Healthcare and Rehabilitation - Fort WKeller, TX 1 of 5Madera Post Acute CenterEl Monte, CA 1 of 5Medallion Post Acute RehabilitationColorado Springs, CO 1 of 5Mesquite Post Acute CareLubbock, TX 1 of 5Millbrook Healthcare and Rehabilitation CenterLancaster, TX 1 of 5Misty Willow Healthcare and Rehabilitation CenterHouston, TX 1 of 5New Orange HillsOrange, CA 1 of 5Northeast Rehabilitation and Healthcare CenterSan Antonio, TX 1 of 5Northgate PlazaIrving, TX 1 of 5Oak View Health And RehabilitationConway, SC 1 of 5Oakwood Care And RehabilitationLakewood, CO 1 of 5Omaha Nursing and Rehabilitation CenterOmaha, NE 1 of 5Onion Creek Nursing and Rehabilitation CenterAustin, TX 1 of 5Park Manor Bee CaveBee Cave, TX 1 of 5Pelican Pointe Health And Rehabilitation CenterWindsor, CO 1 of 5Premier Care Center For Palm SpringsPalm Springs, CA 1 of 5Provo Rehabilitation and NursingProvo, UT 1 of 5Rock Canyon Respiratory And Rehabilitation CenterPueblo, CO 1 of 5Rosewood Rehabilitation CenterReno, NV 1 of 5San Marcos Rehabilitation and Healthcare CenterSan Marcos, TX 1 of 5Sonterra Health CenterSan Antonio, TX 1 of 5SouthlandNorwalk, CA 1 of 5Southland Rehabilitation And Healthcare CenterLufkin, TX 1 of 5Spencer Post Acute Rehabilitation CenterSpencer, IA

Showing 40 of 341; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleSince
DART, GRAYSONIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2023
EATON, SPENCERIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019
BURNAM, SOONIndividualCORPORATE OFFICERsince 01/01/2019
KEETCH, CHADIndividualCORPORATE OFFICERsince 03/01/2011
MOSS, TYLERIndividualCORPORATE OFFICERsince 01/01/2019
CEDAR CITY HEALTHCARE, INC.OrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2019
ENSIGN SERVICES INCOrganizationADP OF THE SNFsince 09/25/2018
IRON HEALTH HOLDINGS LLCOrganizationADP OF THE SNFsince 01/01/2019
STANDARD BEARER HEALTHCARE OP, LPOrganizationADP OF THE SNFsince 01/01/2019
THE ENSIGN GROUP INCOrganizationADP OF THE SNFsince 01/01/2019

CMS files one row per role, so the 15 rows in the source record cover these 10 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.

$9.5M
Net patient revenuemost recent cost report
+9.1%
Operating marginrevenue minus expenses
$1.1M
Related-party expense13% of expenses
Who pays — share of resident-days
Medicaid 68%Medicare 9%Other / private 23%

This home reported $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 13% 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

$343per resident / day
operating cost
$10,417per month
≈ monthly operating cost
$377per day
avg. revenue, all payers

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

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 465143. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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