Highland Care Center
4285 South Highland Drive, Holladay, UT 84124 · For profit - Corporation · 103 certified beds · (801) 278-2839 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- about 27% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 8.0% | 11.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.0% | 3.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.7% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.4% | 16.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.4% | 2.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 13.6% | 15.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 19.2% | 25.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.5% | 3.9% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 21.0% | 21.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.1% | 14.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.9% | 0.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.4% | 91.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 6.9% | 16.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 3.0% | 11.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.90 | 1.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.16 | 1.43 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
54.1% 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 94 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 60.3% 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 63 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 1.20 therapist hours per resident per day in 2026Q1 — more than 98% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 54.1%CMS range 46.0–62.6 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 6.6–13.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 60.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 47.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 49.2% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 98.3% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.7%CMS range 4.8–12.3 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.11 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 103 beds and averages 74.3 residents a day — about 72% occupied, or roughly 29 beds typically open. It usually has some room. 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 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.08 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.98 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.99 hrs/resident/day on weekends vs 3.79 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.21 to 0.77 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 33% 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · D2024-06-11 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services (CMS) system within 14 days of completing a resident's assessment. Specifically, for 1 out of 58 sampled residents, the facility did not transmit a resident's completed discharge MDS assessment to CMS. Resident identifier: 57. Findings included: Resident 57 was admitted to the facility on [DATE] and discharged on 1/19/24 with diagnoses of polyosteoarthritis, pain in left hip, carpal tunnel syndrome bilateral upper limbs, cerebral infarction due to embolism of left middle cerebral artery, essential hypertension, noninfective gastroenteritis and colitis, major depressive disorder, insomnia, ischemic optic neuropathy right eye, and ischemic optic neuropathy left eye. Resident 57's medical record was reviewed from 6/3/24 through 6/11/24. A discharge MDS assessment was completed on 1/31/24. Question A0140 of the assessment had…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-11 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 58 sampled residents, a resident's antihypertensive medication was not held when the diastolic blood pressure (DBP) was below the physician's ordered parameters. Resident identifier: 8. Findings included: Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, Parkinson's disease without dyskinesia without mention of fluctuations, major depressive disorder, generalized anxiety disorder, dementia, chronic pain, and essential hypertension. Resident 8's medical record was reviewed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-11 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents who used psychotropic drugs received gradual dose reductions (GDR) unless clinically contraindicated, in an effort to discontinue these drugs. A GDR must be attempted in two separate quarters, with at least one month between attempts, within the first year in which an individual was admitted on a psychotropic medication or after the facility had initiated such medication, and then annually. Specifically, for 1 out of 58 sampled residents, a resident taking an antidepressant medication for insomnia had not received a GDR on that medication since 2022, and the medication was not clinically contraindicated. Resident identifier: 23. Findings included: Resident 23 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, cerebral infarction due to embolism, nontraumatic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-11 · tag F0773 — isolatedProvide or obtain laboratory tests/services 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, the facility did not obtain laboratory (lab) services only when ordered by a physician; physician assistant; nurse practitioner, or clinical nurse specialist. Specifically, for 1 out of 58 sampled residents, a resident had a basic metabolic panel (BMP) collected on two occasions without a physician's order. Resident identifier: 12. Findings included: Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affection right dominant side, type 2 diabetes mellitus, dementia, altered mental status, atrial fibrillation, cognitive communication deficit, protein-calorie malnutrition, dysphagia, major depressive disorder, anxiety disorder, and essential hypertension. Resident 12's medical record was reviewed on 6/10/24. A physician's order with a start date of 5/15/24, documented BMP to be drawn three times weekly on Monday Wednesday and Friday, Noc…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-11 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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, several surfaces that came into contact with food or food preparation utensils were found to be dirty, staff were observed to not practice hand hygiene, food was exposed to open air, and there were several instances of potential physical food contaminants. Findings included: On 6/5/24, an inspection of the facility kitchen was conducted. On 6/5/24 at 11:26 AM, an observation was made of a metal rack used to store clean meal trays after they were sent through the dishwasher. There was metal plating surrounding the metal rack. The metal plating was noted to be rusty. There was a meal tray touching the rusty surface. There was also a small red bug crawling on the metal rack. On 6/5/24 at 11:29 AM, an observation was made of a vent blowing air from the ceiling. The vent was noted to be covered in a thick layer of dust. On 6/5/24 at 11:34 AM, an observation was made of a metal storage cart used to store clean…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-01-02 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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, the facility did not have detergent for the dish machine, there was cardboard duct taped to the hood vent, refrigerators at the nurses stations were soiled and there were soiled areas in the kitchen. Findings include: 1. On 1/2/24 at 9:49 AM, a dirty meal tray was observed at the bottom of the ice and water cart in the hallway outside room [ROOM NUMBER]. 2. On 1/2/24 at 10:00 AM, an observation was made of the facility dish machine. There were 3 tubes coming from the dish machine. One tube was in a bucket labeled Ultra San, another labeled Rinse Aide and a third labeled Dish Machine Detergent. The Ultra San was a liquid sanitizer. The detergent was observed to be a clear color. The dish machine was observed to have 50 parts per million of chloride bleach. An interview was conducted with Dietary Aide (DA) 1. DA 1 stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-02 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide 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 for 1 of 7 sample residents, that the facility did not ensure a therapeutic diet was offered when there was a nutritional problem and the health care provider ordered a therapeutic diet. Specifically, a resident was not provided a fortified/enhanced diet. Resident identifiers: 4. Findings included: Resident 4 was admitted to the facility on [DATE] with diagnoses which included mycobacterial infections, human immunodeficiency disease (HIV), localized edema, anemia, immune reconstitution syndrome, severe protein calorie malnutrition, hypotension, ascites, splenomegaly and pleural effusion. Resident 4's medical record was reviewed on 1/2/24. On 1/2/24 at 10:15 AM, an observation was made of resident 4 lying in bed with his tube feeding infusing. Resident 4 refused the interview even with translation offered. Resident 4's physician orders revealed a physician's order dated 11/28/23 for a Fortified/enhanced diet, regular texture, with thin…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-03-16 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff were observed to enter transmission based precaution (TBP) rooms without the proper personal protective equipment (PPE) in place, staff were observed to enter the facility through a back entrance and walk down a hallway past residents prior to performing the COVID-19 screening process, staff were observed to have placed a spoon on the top of the medicine cart, then used the spoon to obtain applesauce from a communal container of applesauce, mix the applesauce with the medications and then administer the medication mixture to a resident, and the oxygen tubing for a resident was not routinely changed. Resident identifiers: 20, 69 and 228. Findings Include: On 3/15/22 at 9:53 AM, an observation was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-03-16 · tag F0561 — failed to honor residents' choices — patternHonor 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 3 of 35 sample residents, that the residents were not able to make choices about aspects of their life in the facility, that were significant to the resident. Specifically, residents were not regularly showered three times a week, as was their preference. Resident identifiers: 6, 22, 48. Findings include: 1. Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included rheumatoid arthritis, spinal fusion, paraplegia, urinary tract infection, major depressive disorder, and neuropathy. On 3/14/22, resident 6 was interviewed and stated she was lucky to shower two times a week but only got 1 shower last week. They used to have a shower aide to do the showers now it was just the certified nursing assistants (CNA's). Resident 6 stated she would like to shower 3 times a week and that she has made the staff aware of this. On 3/15/22, resident 6's medical record was reviewed. A form titled Showers located behind…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not develop and implement a comprehensive person-center care plan for 1 of 35 sampled residents, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident did not have a care plan to attain or maintain the highest practicable physical, mental and psychosocial well-being when receiving psychotropic medications. Resident Identifier: 62 Finding include: Resident 62 was initially admitted on [DATE] and again on 2/21/22 with diagnoses that included low back pain, Parkinson's disease, bipolar II disorder, generalized anxiety disorder and cognitive communication deficit. On 3/15/22, Resident 62's medical record was reviewed. Resident 62's 12/19/21 Admitting Minimum Data Set (MDS) revealed he had an active diagnoses of an anxiety disorder, depression and schizophrenia and was receiving…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · D2022-03-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that the facility did not provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene to residents who were unable to carry out activities of daily living (ADLs). Specifically, for 4 out of 35 sampled resident, residents that were dependent on ADLs did not receive showers or bathing assistance in a timely manner and according to the facility schedule for showers. Resident identifiers: 6, 16, 22, and 48. Findings included: 1. Resident 16 was admitted to the facility initially on 7/10/2020 and was re-admitted on [DATE] with diagnoses that included rheumatoid arthritis, polyneuropathy, Sjogren syndrome, chronic osteomyelitis, cellulitis, protein-calorie malnutrition, muscle weakness, sacral ulcers stage 3 and 4, neuromuscular scoliosis, hypo-osmolality and hyponatremia. On 3/13/22 at 2:54 PM, an interview was conducted with resident 16. Resident 16 stated she would like to get a shower at least once per week. Resident 16…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-16 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 35 sampled residents, the facility administered hypertensive medications when the blood pressure measurements were outside of the physician ordered parameters and administered insulin outside of physician ordered parameters. Resident identifier: 37 Findings included: Resident 37 was initially admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses that included right hip osteoarthritis, ventricular fibrillation, cardiomyopathy, congestive heart failure, hypertension, and type II diabetes. On 3/15/22, resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-03-16 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 that the facility did not store food in accordance with professional standards of food service safety. Specifically, food in the freeze and refrigerator was not sealed and was open to air. Findings include: On 3/13/22 at 10:15 AM, an initial tour of the kitchen was conducted. The following item was observed to be unsealed and open to air: 1. In the refrigerator: an unsealed box of beef patties. On 3/16/22 at 10:58 AM, a second walk-through of the kitchen was conducted. The following items were observed to be unsealed and open to air: 1. In the refrigerator: an unsealed box of pre-made omelets. 2. In the dry-storage room freezer: an unsealed box of Salisbury steak patties. On 3/16/22 at 11:00 AM, an interview was conducted with the facility Dietary Manager (DM). The DM accompanied the surveyor on the second walk-through of the dry storage area. The box of Salisbury steak patties was brought to the attention of the DM. The DM stated she had educated her staff about sealing food in the refrigerator and freezer and would need to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-03-16 · tag F0868 — isolatedHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review the facility did not maintain a quality assessment and assurance (QAA) committee consisting of the required members. Specifically, the QAA Committee was held five times in 2021, however the medical director only attended one of those meetings. Findings include: On 3/16/22 at 12:29 PM, an interview and review of the QAA Committee meetings' attendance logs were conducted with the facility's administrator. Review of the QAA Committee meetings in 2021 revealed the committee met on 3/11/21, 4/2/21, 5/12/21, 8/27/21 and 12/27/21. Review of the attendance logs for the 2021 QAA Committee meetings revealed that the medical director attended only the 12/27/21 meeting. The administrator confirmed that the medical director attended only the one meeting in 2021.
- Potential for harm · D2022-03-16 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop 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 the facility did not follow the Centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices (ACIP) guidelines to offer pneumococcal immunizations for 1 of 35 sampled residents. Specifically, a current resident, who had resided in the facility since June 2017 was not offered the 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax23) per CDC and ACIP guidelines. Resident Identifier: 50 Findings include: Resident 50 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident (stroke), hemiplegia or hemiparesis, gastroesophageal reflux disease, hyperlipidemia, thyroid disorder, osteoporosis, malnutrition, anxiety disorder, and depression. On 3/12/22, Resident 50's medical record was reviewed. Resident 50's immunization history revealed that she was offered but refused the 13-valent pneumococcal conjugate vaccine (PCV13, Prevnar13) on 6/2/17. There was no documentation that the PPSV23, Pneumovax23…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-11-07 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 2. Resident 3 was admitted on [DATE] and readmitted on [DATE] with diagnosis which included heart failure, fracture of left wrist and hand, fracture of nasal bones, atrial fibrillation, respiratory failure, dysphagia, encephalopathy, pain, hypertension, hyperlipidemia, insomnia, and muscle weakness. On 11/4/19 at 2:38 PM, resident 3 was observed lying in her bed. Resident 3 had no falls mats on the floor by her bed. Resident 3's call light was observed to be in her recliner which was not accessible from the bed. On 11/5/19 at 7:26 AM, an observation was made of resident 3's room. There were no fall mats observed to be anywhere in resident 3's room. On 11/5/19 at 9:52 AM, an observation was made of resident 3 sitting in her wheelchair in her room. Resident 3's call light was behind her on her nightstand, which was not accessible from her wheelchair. On 11/5/19 at 1:52 PM, an observation was made of resident 3. Resident 3 was sitting in her recliner; resident 3's tab alarm was not in place. Resident 3's medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-11-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 3 of 38 sample residents, that the facility did not ensure that the resident's environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility staff did not provide adequate supervision to prevent falls from occurring and care planned interventions were not implemented. Resident identifiers: 3, 38, and 50. Findings include: 1. Resident 3 was admitted on [DATE] and readmitted on [DATE] with diagnosis which included heart failure, fracture of left wrist and hand, fracture of nasal bones, atrial fibrillation, respiratory failure, dysphagia, encephalopathy, pain, hypertension, hyperlipidemia, insomnia, and muscle weakness. On 11/4/19 at 2:38 PM, resident 3 was observed lying in her bed. Resident 3 had no falls mats on the floor by her bed. Resident 3's call light was observed to be in her recliner which was not accessible…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-11-07 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 of 38 sample residents, that the pharmacist did not report irregularities in the drug regimen review to the attending physician, the facility's Medical Director, and Director of Nursing. Irregularities include, but are not limited to, any medication when used without adequate monitoring or without adequate indications for its use. Specifically, the pharmacist did not report the irregularity of the use of antipsychotics and antidepressants for residents that did not have a diagnosis of a serious mental illness, and to residents with dementia. Resident identifiers: 25 and 50. Findings include: 1. Resident 50 was admitted to the facility on [DATE] with diagnoses which included left pubic fracture, lumbar vertebra fracture, sacrum fracture, rib fracture, left arm cellulitis, gait abnormality, type 2 diabetes mellitus, asthma, hypertension, dementia without behavioral disturbance, and major depressive disorder. On 11/5/19 resident 50'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.
- Potential for harm · Ecited before2019-11-07 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, staff were observed in the food prep area without a hairnet. Resident identifier: 9. Findings include: 1. On 11/4/19 at 11:40 AM, an observation was made of Dietary Tech (DT) 1 with her hair up in a bun on top of her head and hair was hanging down on her neck and around her face. DT 1 was observed with the hair net only covering her bun, the rest of her hair uncovered. DT 1 was observed to go in and out of the kitchen with uncovered hair six times. On 11/5/19 at 7:34 AM, an observation was made of the Certified Nursing Assistant (CNA) Coordinator helping to serve breakfast. The CNA Coordinator was observed not wearing a hair net. The CNA Coordinator was observed to go into the kitchen twice. On 11/4/19 at 4:45 AM, an observation was made of the Speech Language Pathologist (SLP) go into the kitchen to grab food for a resident. The SLP had her hair down and 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.
- Potential for harm · D2019-11-07 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 of 38 sample residents, that the facility did not ensure that the resident assessment information was accurate. Specifically, a resident on dialysis was documented as not being on dialysis on the Minimum Data Set (MDS) Assessment, and a resident who had sustained multiple falls were not documented on two Quarterly MDS Assessments that documented the falls. Resident identifiers: 3 and 9. Findings include: 1. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses which included acute respiratory failure, hypoxemia, end stage renal disease , dependence on renal dialysis, atherosclerosis, heart failure, hypertension, shortness of breath, hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, hyperlipidemia, non-st elevation myocardial infarction, peripheral vascular disease, peripheral neuropathy, and major depressive disorder. On 11/4/19 resident 9's medical record was reviewed. 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.
- Potential for harm · D2019-11-07 · tag F0679 — failed to provide activities — isolatedProvide 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, interview and record review it was determined for 1 of 38 sample residents that the facility did not provide an ongoing program to support residents choice, of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychological well-being of each resident, encouraging both independence and interaction in the community. Resident identifier: 13 Findings include: Resident 13 was admitted to the facility on [DATE] with diagnoses which included rheumatoid arthritis, vertigo of central origin, anxiety disorder, chronic pain, syncope and collapse, and major depressive disorder. On 11/4/19 at approximately 10:26 AM, resident 13 was observed awake lying on her back in bed and an interview was conducted. Resident 13 stated she had not gone to the facility-sponsored group activities due to her rheumatoid arthritis. Resident 13 stated that it was too painful to sit in a wheelchair for 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.
- Potential for harm · Dcited before2019-11-07 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 38 sample residents, that the facility did not ensure that residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record and that the facility did not ensure that irregularities identified by the pharmacist were reported to the attending physician and director of nursing, and the reports were acted upon. Specifically, one resident had no irregularities noted by the facility pharmacist when taking an antipsychotic medication and one resident had a pharmacy recommendation that had not been followed up on in a timely manner. Resident identifiers: 50. Findings include: Resident 50 was admitted to the facility on [DATE] with diagnoses which included left pubic fracture, lumbar vertebra fracture, sacrum fracture, rib fracture, left arm cellulitis, gait abnormality, type 2 diabetes mellitus, asthma, hypertension, dementia without…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-07 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review it was determined for 1 of 38 sample residents that the facility did not ensure that it was free from medication error rate of 5% or greater. Specifically, observations of thirty-three medication opportunities, on 11/6/19, revealed seven medication errors which resulted in a 21.21% medication error rate. Resident identifier: 51. Findings include: 1. On 11/6/19 at 7:30 AM, medication administration was observed with Licensed Practical Nurse (LPN) 1. Between 8:26 AM and 8:56 AM, LPN 1 was observed to prepare and administer the following medications to resident 51: a. Phos-Nak 280-160-250 mg (milligrams) 1 powder packet via naso-gastric (NG) tube. b. Potassium Chloride ER 10 mEq (mill-equivalents) via NG tube. c. Dexamethasone 8 mg via NG tube. d. Gabapentin 100 mg via NG tube. e. Multivitamin with minerals, 1 tablet via NG tube. f. Lasix 20 mg via NG tube. g. Diflucan 150 mg via NG tube. h. Ascorbic Acid 500 mg via NG tube. i. Metformin 1000 mg via NG tube. Resident 51's physician orders were reconciled against the administered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-07 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that 2 of 38 sample residents was free of significant medication errors. Specifically, two residents were administered crushed potassium extended released (ER). Resident identifier: 51 and 206. Findings include: 1. Resident 51 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of stomach, hyponatremia, weakness, anorexia, nutritional anemia, type 2 diabetes mellitus, hyperlipidemia, hypertension, mononeuropathy of left lower limb, protein-calorie malnutrition, and dysphagia. On 11/6/19 at 8:26 AM, an observation was made of medication administration to resident 51 by Licensed Practical Nurse (LPN) 1. LPN 1 prepped Potassium Chloride ER 10 mEq (mill-equivalents), LPN 1 was observed to crush the potassium and place it in a cup of water. LPN 1 was then observed to draw up the water and crushed potassium into a syringe and administered it to resident 51 via her naso-gastric (NG) tube. On 11/6/19 at 8:53 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.
- Potential for harm · D2019-11-07 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined that the facility did not ensure safe storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medications. Specifically, medications that had expired were still available for use. Findings include: 1. On [DATE] at 9:20 AM, the South Hall medication cart was observed. There was a Glucagon Emergency Kit for Low Blood Sugar 1 milligram injection with an expiration date on the package of 5/2019. The Pharmacy label had an expiration date of 3/2020. On [DATE] at 9:27 AM, the Central Hall medication cart was observed. The cart did not contain a Glucagon Emergency Kit for Low Blood Sugar. On [DATE] at 9:20 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the expiration date on the product package was the correct expiration date, and the pharmacy label was incorrect. On [DATE] at 9:27 AM, an interview 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to EDURO HEALTHCARE — 34 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 2.4 | +2.6 vs chain |
| Health inspection | 4 of 5 | 2.4 | +1.6 vs chain |
| Staffing | 4 of 5 | 2.2 | +1.8 vs chain |
| Quality measures | 5 of 5 | 3.1 | +1.9 vs chain |
The other 33 homes this chain runs (chain average 2.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BEWSEY, MICHAEL | Individual | CORPORATE OFFICER | since 06/29/2017 |
| DAVIDSON, CRAIG | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/20/1990 |
| LANGFORD, SCOTT | Individual | CORPORATE OFFICER | since 07/01/2014 |
| EDURO HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 06/29/2017 |
| HIGHLAND NURSING AND REHAB CENTER, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 06/29/2017 |
CMS files one row per role, so the 7 rows in the source record cover these 5 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.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $4.1M paid to related parties — landlords or management companies under common ownership — equal to about 27% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in UT
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Utah Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 465078. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-06-11, 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 →
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