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Thatcher Brook Rehabilitation & Care Center

1795 South Chelemes Way, Clearfield, UT 84015 · For profit - Limited Liability company · 30 certified beds · (801) 614-5700 Medicare only — no Medicaid

Call the home — (801) 614-5700 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 23 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (23) — 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

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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 5 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
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3225 W Gordon Ave Ste 1 · (801) 397-6150 · Call to confirm hours
Pharmacy
3225 W Gordon Ave · (801) 544-7979 · Call to confirm hours
Grocery
1475 S State St · (801) 825-0788 · Call to confirm hours
Park
2050 S 575 E · (801) 525-2700 · 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 5 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Short-stay residents who newly got an antipsychotic medication0.0%0.9%1.4%better
Short-stay residents given the seasonal flu vaccine94.8%91.0%79.4%better
Short-stay residents rehospitalized after admission20.7%16.5%22.6%typical
Short-stay residents with an outpatient ER visit12.9%11.6%12.0%typical

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.

68.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 211 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

68.9%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
68.3%U.S. median 56.6%
Met the expected recovery
1.47U.S. median 0.31
Therapy hours / resident / day
0.90hours / resident / day
Physical therapy
0.53hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 68.3% 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 82 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 1.47 therapist hours per resident per day in 2026Q1 — more than 99% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 14% 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 SNF68.9%CMS range 63.0–73.851.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 6.5–13.210.7%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 discharge68.3%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 discharge63.4%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 discharge79.3%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 setting99.0%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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.8%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 hospitalization7.1%CMS range 4.8–10.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.161.02Oct 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

2.09
RN hours/ resident / day
0.81
LPN hours/ resident / day
2.87
Aide hours/ resident / day
5.78
Total nurse hours/ resident / day
1.49
RN hoursweekends
30.6%
Total nursing turnover
8.3%
RN turnover

How full it usually is: this home is certified for 30 beds and averages 27.6 residents a day — about 92% occupied, or roughly 2 beds typically open. It runs fairly full. 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 5.78 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 2.09 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.87 is at or above 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 4.62 hrs/resident/day on weekends vs 6.25 on weekdays — 26% thinner on weekends — a notable drop. RN hours go from 2.34 to 1.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 31% is below 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

13
deficiencies at the latest standard inspection (2025-07-23)
0
at the previous standard inspection (2023-09-27)

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.

23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.

  • Potential for harm · E2025-07-23 · tag F0761 — failed to label and store drugs safely — pattern
    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, interview, and record review it was determined, for 4 of 26 sampled residents, that the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. Specifically, an insulin pen and a vial of insulin were not dated with an open date or expiration date. Additionally, medications were found in the sink in the medication room and a medication cart was left unlocked and unattended. Resident identifiers: 2, 21, 24, and 31. Findings included: 1. Resident 21 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, end stage renal disease, displaced fracture of right tibia. A review of resident 21’s medication orders indicated: a. Insulin lispro solution 100 unit/mL (milliliter) Administer 4 units with meals. Start date 7/8/25. b. Insulin lispro solution 100 unit/mL Administer 12 units…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-07-23 · 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 and interview, for 8 of 26 sampled 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 food quality, the test tray did not appear appetizing and was not palatable. Findings included: On 7/21/25 at 10:58 AM, an interview was conducted with resident 32 who stated the food was only good some of the time and alternatives were not offered. Resident 32 stated he was not pleased with the meals. On 7/21/25 at 1:17 PM, an interview was conducted with resident 25 who stated she had not been eating much because the food did not taste good. On 7/21/25 at 12:41 PM, an interview was conducted with resident 7 who stated she was disappointed with her lunch meal. Resident 7 received a plate of spaghetti with very small pieces of meat and green peas mixed in. Her meal also included a pudding-like dessert on the side. Resident 7 stated the meal was very unappetizing. On 7/21/25 at 8:56 AM, an interview…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-07-23 · 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 walk-in refrigerator were open to the air, the stove was not clean, the top of the oven was not clean, meat in the refrigerator was not labeled and a large bucket of pickles did not have an open date.Findings included:On 7/21/25 at 8:40 AM, an initial walk-through of the kitchen was conducted. In the tall, white, reach-in freezer, a bulk box of diced carrots was open to air and a bulk box of peas was open to air. In the tall, silver, reach-in freezer, a box of French toast was open to air and a box of frozen cookie dough was open to air. In the walk-in freezer, a box of sausage links was open to air. The stove was observed to have crumbs, debris and grease on it. On 7/23/24 at 10:26 AM, a second walk-through of the kitchen was conducted. The stove had crumbs, debris and grease on it. The top of the oven was observed to have a white powder on it. The tall, white,…

    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 before2025-07-23 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 3 out of 26 sampled residents, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, observations were made of staff not donning Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP), staff were observed not performing hand hygiene during dressing changes and cross contamination was observed during a dressing change with improper cleaning of the insertion site. Resident identifiers: 3, 15, and 18.Findings included:1. Resident 15 was admitted to the facility on [DATE] with diagnoses which consisted of infective endocarditis, atrial fibrillation, chronic kidney disease, cystitis, type 2 diabetes mellitus, bacteremia, hypolipidemia, and hypokalemia. Resident 15's medical records were reviewed. On 6/30/25, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-23 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her 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 observation and interview it was determined that for 1 of 26 sampled residents, that the facility did not treat each resident with respect and dignity and care for each resident in a manner and environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality. Specifically, an observation was made of staff standing while feeding a resident. Resident identifier: 35.Findings included: Resident 35 was admitted to the facility on [DATE] with diagnoses which included cellulitis, sepsis, and hypertension. On 7/21/25 at 12:21 PM, an observation was made of resident 35 laying in bed with the head of the bed elevated. Resident 35's bed was in the highest position. Certified Nursing Assistant (CNA) 1 was observed to be standing to the left side of resident 35's bed feeding the resident. On 7/23/25 at 8:22 AM, an interview was conducted with CNA 2. CNA 2 stated that resident 35 required assistance with eating. CNA 2 stated that because resident 35 was a hoyer…

    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 · D2025-07-23 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, for 1 of 26 sampled residents, the facility did not notify the resident or the resident's representative of the transfer or discharge, and the reason, in writing at the time of discharge. Additionally, the resident was not informed of the bed hold policy in writing with specification of the duration during which the resident was permitted to return and resume residence in the facility. Specifically, a resident who was discharged to the hospital was not provided discharge documentation. Resident identifier: 2Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses that included fracture of left tibia and fibula, respiratory failure with hypoxia, neuralgia, and neuritis, type 2 diabetes, anxiety disorder, epilepsy and morbid obesity.Resident 2's medical records were reviewed between 7/21/25 - 7/23/25.A progress note dated 7/20/25 at 12:30 PM revealed, resident 2 was discharged to the hospital after the family informed staff she was having what…

    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 · D2025-07-23 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 2 out 26 sampled residents, that the facility did not provide an ongoing program to support residents in their choice of activities both facility-sponsored group and individual activities and independent activities designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community based on the comprehensive assessment and care plan. Specifically, there were no activities besides bingo three times a week and residents complained of not enough activities. Resident identifiers: 25 and 30.Findings included:1. Resident 30 was admitted to the facility on [DATE] with diagnoses which included generalized anxiety disorder, major depressive disorder, and weakness. On 7/21/25 at 9:37 AM, an interview was conducted with resident 30. Resident 30 stated that there were no activities other than bingo and that there were some days with no activities. On 7/21/25 at…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 1 of 26 sampled residents, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision to prevent accidents. Specifically, a resident did not have new interventions implemented after falls. Resident identifier: 30. Findings included: Resident 30 was admitted to the facility on [DATE] with diagnoses which included lack of coordination, weakness, and white matter disease. Resident 30's medical record was reviewed 7/21/25 through 7/23/25. On 6/22/25 a Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) assessment was completed on resident 30. Resident 30 scored a 5 which indicated severe cognitive impairment. A review of resident 30's progress notes revealed the following falls: a. On 6/24/25 at 1:04 PM, [Resident 30] was found on the floor in her bathroom. She was pulling her pants down when she fell. She denies feeling dizzy or…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-23 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, it was determined for 1 of 26 sampled residents, the facility did not ensure that residents who require dialysis receive such services consistent with professional standards of practice. Specifically, the facility was not providing immediate monitoring and documentation of resident's vital signs and the status of a resident's dialysis fistula upon return from the dialysis treatment center. Resident identifiers: 4.Findings included:Resident 4 was admitted to the facility on [DATE] with diagnoses which included sepsis, end stage renal disease, and heart failure.Resident 4's medical record was reviewed on 7/21/25 through 7/23/25. On 7/21/2025 at 1:27 PM, an interview was conducted with resident 4. Resident 4 stated that after he finished his treatment at the dialysis center, vital signs and weights were collected and documented on the Dialysis Progress Note for him to give to the facility. Resident 4 stated that when he returned to the facility from the dialysis center a…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-23 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, for 1 of 26 sampled residents, the facility did not have menus that met the nutrition needs of residents in accordance with established nutrition guidelines, and did not follow the menu for a resident with special dietary needs. Specifically, a resident who required a specialized diet was not given adequate substitutions for listed menu items. Resident identifier: 7.Findings included:On 7/21/25 at 12:41 PM, an interview was conducted with resident 7 who stated she was disappointed with her lunch. Resident 7 stated she had recently discontinued receiving tube feedings and was getting used to swallowing again. Resident 7's lunch plate was observed to have spaghetti with small pieces of meat and green peas mixed in. There was a small dish of a pudding-type dessert on the side. Resident 7 noted the menu stated spaghetti, garlic bread and a green salad was being served. There was no substitute for the garlic bread or the salad provided with resident 7's meal.Resident 7's medical record was reviewed between 7/21/25 and 7/23/25.A nutrition…

    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
Show the remaining 13 citations
  • Potential for harm · D2025-07-23 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 1 of 26 residents sampled, that the facility did not ensure that each resident received food that accommodated the resident allergies, intolerances, and preferences. Specifically, a resident had a food preference dislike of pork and received pork products as meal items. Resident identifier: 15.Findings included:Resident 15 was admitted to the facility on [DATE] with diagnoses which consisted of infective endocarditis, atrial fibrillation, chronic kidney disease, cystitis, type 2 diabetes mellitus, bacteremia, hypolipidemia, and hypokalemia.On 7/21/25 at 9:47 AM, an interview was conducted with resident 15. Resident 15 stated that she had a food preference that indicated a dislike of pork and the facility gave her pork products three times last week. Resident 15's medical records were reviewed. On 7/2/25, resident 15's Nutrition Screening Intake Form documented food preference dislikes as pork, ham, and sausage. On 7/22/25 at 8:27 AM, a…

    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 · Dcited before2025-07-23 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    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 26 sampled residents, that the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor antibiotic use. Specifically, a resident was prescribed an antibiotic prophylactically for the treatment of chronic urinary tract infections (UTI) without any documented evidence that the resident was showing signs and symptoms of a current infection. Resident identifier: 30. Findings included:Resident 30 was admitted to the facility on [DATE] with diagnoses which included neoplasm of right kidney, history of urinary tract infections (UTI), and hypertension. Resident 30's medical records were reviewed. On 6/19/25, resident 30 had a physician order for Macrobid capsule 100 milligram (mg) by mouth daily. The order had special instructions that documented prophylaxis for chronic UTI. The order was discontinued on 6/26/25. On 6/27/25, resident 30 had a physician order for Macrobid capsule 100 milligram…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-23 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 5 residents sampled, that the facility did not offer a pneumococcal immunization, unless the immunization was medically contraindicated or the resident had already been immunized. Specifically, the facility did not have evidence to demonstrate that the resident was administered, offered, or declined the second dose of the pneumococcal immunization series. Resident identifier: 29.Findings included:Resident 29 was admitted to the facility on [DATE] with diagnoses which included fracture of the right fibula, congestive heart failure, chronic kidney disease, type 2 diabetes mellitus, presence of prosthetic heart valve, cardiomyopathy, and hypertension. Resident 29's medical records were reviewed. Resident 29's Preventative Health Care documented that resident 29 received the PCV -13 (Prevnar - 13) pneumococcal vaccine on 9/29/15. No documentation of a second pneumococcal vaccine administration or declination was found for resident 29. On 5/1/25,…

    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 · Fcited before2022-06-23 · tag F0880 — failed to prevent and control infections — widespread
    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, interview and record review it was determined, for 4 of 16 resident's sampled, that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, observation were made of staff not screening at the front entrance for COVID-19, staff were observed inside the facility without the required Personal Protective Equipment (PPE) donned, staff were observed with the PPE donned incorrectly, the glucometer was not disinfected per the recommended disinfectant wet time to kill blood borne pathogens, observations were made of cross contamination during wound care, staff were not aware of droplet precautions for new admissions, observations were made of staff exiting droplet precaution rooms without disinfecting their eye protection and changing their KN95 masks, rooms on droplet…

    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 · E2022-06-23 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance for two of the same deficiencies identified on an infection control survey as well as the previous recertification survey. Resident identifiers 5, 11, 120, and 223. Findings include: 1. Based on interview and record review it was determined that the facility did not ensure that the infection prevention and control program (IPCP) included a system to monitor antibiotic use. Specifically, the facility IPCP had not been tracking the facility infections and antibiotic use since February 2022. It should be noted that the facility also received this citation on the last recertification survey which ended on 12/19/19. During that survey it was determined that the facility did not ensure that the infection prevention and control program (IPCP) included a system to monitor antibiotic use. Specifically, the…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-06-23 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined that the facility did not ensure that the infection prevention and control program (IPCP) included a system to monitor antibiotic use. Specifically, the facility IPCP had not been tracking the facility infections and antibiotic use since February 2022. Findings include: On 6/23/22, a copy of the facility's surveillance and tracking for antibiotic stewardship was requested. The Administrator (ADM) provided the binder that contained the surveillance and tracking. However, no surveillance and tracking for March, April, May or June 2022 was located in the binder. A review of February 2022's antibiotic stewardship tracking was completed. The tracking included a list of residents with their diagnoses and what antibiotic the resident was prescribed. The tracking did not include information to indicate if the resident had any cultures performed in order to demonstrate compliance with antibiotic stewardship. In addition, the tracking included the names of three residents who were receiving a prophylactic antibiotic, but not an indication…

    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 · D2022-06-23 · 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 out of 16 sampled residents, that the facility did not consult with the resident's physician and notify, when there was a need to alter the resident's treatment. Specifically, medications were not administered due to not being available from the pharmacy. Resident identifier 12. Findings included: Resident 12 was admitted to the facility on [DATE] with diagnoses which consisted of fracture of left ischium, congestive heart failure, chronic respiratory failure, hypothyroidism, depression, anxiety disorder, hypertension, pain, and gastro-esophageal reflux disease. On 6/22/22 resident 12's medical records were reviewed. Review of resident 12's physician orders revealed the following: a. Reglan (metoclopramide) 5 milligram (mg) tablet three times a day. The order was initiated on 5/16/22. b. Meloxicam (mobic) 15 mg tablet every day. The order was initiated on 5/17/22. Review of resident 12's June 2022 Medication Administration Record (MAR) revealed the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-23 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when 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 observation, interview, and record review it was determined, for 1 of 16 sample residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice. Specifically, facility staff were not cleaning the resident's Continuous Positive Airway Pressure (CPAP) machine, mask and tubing. Resident identifier: 5. Findings included: Resident 5 was admitted to the facility on [DATE] with diagnoses which included paraplegia, acute respiratory failure, atrial fibrillation, sacral region pressure ulcer, type II diabetes, obstructive sleep apnea, and congestive heart failure. On 6/21/22 at 2:11 PM, an interview was conducted with resident 5. Resident 5 stated he used a CPAP machine at night. Resident 5 stated the staff did not wear gowns when they entered his room when the CPAP machine was in use. Resident 5 stated if he wanted the CPAP machine cleaned he would need to do that by himself because the staff did not do that at…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-23 · 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 interview and record review it was determined, for 1 of 16 sampled residents, that the facility did not provide pharmaceutical services to meet the needs of each resident. Specifically, medications were not administered due to being unavailable from the pharmacy. Resident identifier 12. Findings included: Resident 12 was admitted to the facility on [DATE] with diagnoses which consisted of fracture of left ischium, congestive heart failure, chronic respiratory failure, hypothyroidism, depression, anxiety disorder, hypertension, pain, and gastro-esophageal reflux disease. On 6/22/22 resident 12's medical records were reviewed. Review of resident 12's physician orders revealed the following: a. Reglan (metoclopramide) 5 milligram (mg) tablet three times a day. The order was initiated on 5/16/22. b. Meloxicam (mobic) 15 mg tablet every day. The order was initiated on 5/17/22. Review of resident 12's Medication Administration Record (MAR) revealed the following: a. On 6/13/22 at 7:30 AM, the Meloxicam 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-23 · tag F0777 — isolated
    Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
    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 determine, for 1 of 16 sampled residents, that the facility did not obtain radiology services only when ordered by a physician. Specifically, x-rays were obtained without a physician order. Resident identifier 120. Findings included: Resident 120 was admitted to the facility on [DATE] with diagnoses which consisted of fracture of right radius, nondisplaced fracture of the right ulna styloid process, fracture of right pubis, fracture of right clavicle, type 2 diabetes mellitus, chronic kidney disease stage 3, encephalopathy, peripheral vascular disease, seizures, hypertension, non-pressure chronic ulcer of left foot, pain, major depressive disorder, and gastro-esophageal reflux disease. On 6/22/22, resident 120's medical records were reviewed. On 6/20/22, x-rays were obtained of resident 120's right clavicle and right wrist. Review of resident 120's facility orders, the facility standing orders, and the hospital discharge orders revealed no physician order for an x-ray…

    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 · D2022-06-23 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 of 16 sample residents, that the facility did not maintain medical records on each resident that were complete and accurately documented. Specifically, documentation regarding a resident's Physician Orders for Life Sustaining Treatment (POLST) was not in the medical record and a resident's immunization history was not in the medical record. Resident identifiers: 19 and 120. Findings included: 1. Resident 19 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, traumatic subdural hemorrhage, hypothyroidism, hyperlipidemia, end stage renal disease, type II diabetes and congestive heart failure. On 6/21/22, Resident 19's medical record was reviewed. No POLST form was found in resident 19's medical record on 6/21/22, 6/22/22, or 6/23/22. On 6/23/22 at 8:41 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated the POLST form is done on admission and it was the admission nurse's responsibility to ensure 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-23 · tag F0886 — failed to test for COVID-19 as required — isolated
    Perform COVID19 testing on residents and staff.
    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 8 sampled facility staff members, that the facility did not ensure that routine testing of facility staff for COVID-19 was completed based on the parameters set forth by the Secretary. Specifically, routine testing of not up to date vaccinated staff members, based on the county transmission rate, was not completed. Staff identifiers: Licensed Practical Nurse (LPN) 2 and Dietary Staff Member (DSM) 1. Findings included: On 6/21/22, a list of staff that were partially vaccinated, fully vaccinated and had vaccination exemptions was provided. According to the Center for Disease Control and Prevention (CDC), staff are considered up to date with COVID-19 vaccines when they have received all doses in the primary series and all boosters recommended. (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html?s_cid=11747:cdc%20up%20to%20date%20vaccine:sem.ga:p:RG:GM:gen:PTN:FY22). LPN 2 and DSM 1 were documented on the staff matrix as completely…

    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 · D2022-06-23 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 interviews and record review, it was determined, the facility did not ensure the resident's medical record included documentation that indicates, at a minimum, the following: that the resident or resident representative was provided education regarding the benefits and potential risks associated with Coronavirus Disease - 2019 (COVID-19) vaccine; each dose of COVID-19 vaccine administered to the resident; or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Specifically, for 1 of the 5 sampled residents, the facility did not keep documentation within the residents' medical record regarding the residents' COVID-19 vaccination refusal or education of the benefits and potential risks associated with COVID-19 vaccination. Resident identifiers: 122. Findings include: Resident 122 was admitted to the facility on [DATE] with diagnoses which included pneumonia, encephalopathy, chronic respiratory failure, bipolar disorder, chronic obstructive pulmonary disease,…

    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

“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.

Who owns this facility

Owner / managerTypeRoleShareSince
PULHAM, RANDYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTORNO PERCENTAGE PROVIDEDsince 04/01/2025
STUCKI, RONIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR32%since 07/20/2022
WILCOX, JOHNIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR15%since 07/20/2022
COMPAS, DAVIDIndividualDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; ADP OF THE SNFsince 04/01/2025
STUCKI, CLAYIndividualDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROLsince 04/03/2025
ARCHULETA, BROOKEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/09/2025
ANDERSON, AARONIndividualADP OF THE SNFsince 06/01/2022

CMS files one row per role, so the 13 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$4.6M
Net patient revenuemost recent cost report
+2.9%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 0%Medicare 47%Other / private 53%

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

Cost & finances

$464per resident / day
operating cost
$14,120per month
≈ monthly operating cost
$479per day
avg. revenue, all payers

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

What families pay in UT

Paying with Medicaid

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Utah Medicaid page for homes that do.

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 465169. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-23, 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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