Fairfield Village Rehabilitation
1203 North Fairfield Road, Layton, UT 84041 · For profit - Limited Liability company · 40 certified beds · (801) 807-0113 Medicare only — no Medicaid
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0602), cited May 2026
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- nursing-staff turnover (63%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 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
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 |
| 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 fell from 5 to 4 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 |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 2.2% | 0.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 93.8% | 91.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.3% | 16.5% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.4% | 11.6% | 12.0% | better |
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.
62.0% 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 416 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 71.7% 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 226 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 1.09 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 13% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 62.0%CMS range 57.8–66.1 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 7.3–13.2 | 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 | 71.7% | 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 | 72.6% | 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 | 73.9% | 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 | 98.3% | 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 | 98.8% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.7% | 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 | 1.7% | 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 | 4.6%CMS range 2.9–6.9 | 7.1% | Oct 2023–Sep 2024 | better than U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 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 40 beds and averages 32.3 residents a day — about 81% occupied, or roughly 8 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 5.06 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.67 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 4.68 hrs/resident/day on weekends vs 5.21 on weekdays — 10% thinner on weekends. RN hours go from 2.11 to 1.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 63% is well above 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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · F2026-05-28 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure 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, the facility did not have menus that were prepared in advance and were followed. Specifically, the menu had 4 ounces of Asian noodles and two small egg rolls for lunch and residents were served unmeasured Asian noodles and one small egg roll. Findings included:Review of the facility lunch menu for a regular diet on 5/27/26 documented the meal options and serving size of each food item were Egg Drop Soup (6 ounces), General Tso's Chicken (3 ounces), Asian Noodles (4 ounces), Oriental Blend Vegetables (4 ounces), and Mini Egg Rolls (2 each).On 5/27/26 at 11:53 AM, an observation was made of the lunch meal service. An observation was made of the Chef during plating of the lunch meal. The Chef was observed to serve the Asian Noodles with tongs and the amount was not measured and varied from plate to plate. The Chef was observed to place one egg roll onto each regular diet plate. On 5/27/26 at 11:55 AM, an interview was conducted with Chef 1. Chef 1 stated that she was serving 3 ounces of fries and noodles with the serving tongs. Chef 1…
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 before2026-05-28 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, food items in the refrigerator and freezer were undated, and sanitation buckets did not meet the required sanitation testing levels.Findings included:1. On 5/26/26 at 8:12 AM, an initial tour of the kitchen was conducted. The following observations were made:a. A male kitchen staff member was observed to be serving food onthe tray line and was not wearing a hair net.b. Celery chunks were not dated in the refrigerator.c. A bag of mozzarella cheese was opened and undated in the refrigerator.d. A bag of cheese slices was opened and undated in the refrigerator.e. Sliced roast beef in a metal container was undated in the refrigerator.f. A bag of garlic bread was opened and undated in the freezer.g. A bag of frozen carrots was opened and undated in the freezer.h. A bag of frozen meat patties was open to air and undated in the freezeri. A bag of meatballs was opened and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-28 · tag F0609 — failed to report abuse allegations — patternTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that the facility did not ensure that all alleged violations involving abuse, neglect, and misappropriation of resident property were reported immediately, but no later than 2 hours after the allegation was made, if the events involved abuse or resulted in serious bodily injury, to the State Survey Agency (SSA) and Adult Protective Services (APS); and the results of the investigation were reported to the SSA within 5 working days of the incident. Specifically, for 3 of 42 sampled residents, the facility did not report to the SSA alleged violations involving abuse or neglect no later than 2 hours after the allegation was made or submit the results of the investigation to the SSA within 5 working days; and the facility did not report alleged violations to APS. Resident identifiers: 48, 66, and 67. Findings included:1. Resident 48 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, sepsis, adult failure to thrive,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-28 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review it was determined that the facility did not store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys. Specifically, for 11 of 42 sampled residents, medications were stored at temperatures below the manufacturer's instructions. Furthermore, the facility's Purified Protein Derivative (PPD), the testing solution used in the Tuberculosis (TB) screening process for new admits, was stored at temperatures below the manufacturer's instructions. Resident identifiers: 9, 10, 19, 30, 37, 59, 76, 77, 78, 79, and 80.Findings Included: On 5/27/26 at 10:10 AM, an observation was made of the facility's medication storage refrigerator with Registered Nurse (RN) 3, who confirmed the thermometer in the refrigerator read 32.5 degrees Fahrenheit. RN 3 confirmed that the facility's TB testing solution and residents' overstocked medications were stored in the refrigeratorOn 5/27/26 at 10:18 AM, an interview was conducted with the Director of Nursing (DON),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-05-28 · tag F0809 — failed to serve meals on a reasonable schedule — patternEnsure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility did not provide at least three meals daily with no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may lapse between a substantial evening meal and breakfast the following day if a resident group agreed to this meal span. Specifically, the dinner and breakfast were served 15 hours apart and there was no substantial evening snack being offered. Findings included:Scheduled meal times for the facility were posted. Breakfast was served at 7:30 AM-8:30 AM, lunch was served at 12:00 PM-1:00 PM, and dinner was served at 5:15 PM-6:30 PM. On 5/27/26 an observation was made of the breakfast service. The following was observed:a. The first breakfast meal was served at 7:47 AM.b. At 8:51 AM, a resident in the dining room asked if she was going to be served breakfast sometime this morning.c. At 9:08 AM, the last breakfast meal was served to a resident in the 100 hallway. The resident stated it was about time. On 5/27/26 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-05-28 · tag F0880 — failed to prevent and control infections — patternProvide 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 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. Specifically, for 3 of 42 sampled residents, Enhanced Barrier Precautions [EBP] were not being implemented as ordered. Additionally, staff were not following hand hygiene procedures while serving meals. Furthermore, the facility's Tuberculosis (TB) screening process for new admits was inaccurate due to the testing solution (Purified Protein Derivative, or PPD) being compromised. Resident identifiers: 4, 38, and 28.Findings included:1. HAND HYGIENE On 5/27/26 at 11:45 AM, an observation of lunch service was conducted. The following was observed:a. Certified Nursing Assistant (CNA) 3 was assisting residents in the dining room while wearing gloves. CNA 3 was observed to touch multiple surfaces and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-28 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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 the residents were free from misappropriation of resident property. Specifically, for 2 of 42 sampled residents, a staff member diverted narcotic medications. Resident identifiers: 68 and 73.Findings included:1. Resident 68 was admitted to the facility on [DATE] with diagnosis that included fracture of upper end of right humerus, subsequent encounter for fracture with routine healing, pneumonia, and dementia. Resident 68 was discharged from the facility on 1/14/26. On 1/11/26, a physician order was started for Pregabalin Oral Capsule 100 milligram (MG) Give 1 capsule by mouth three times a day for nerve pain.On 1/11/26, a physician order was started for oxycODONE HCl (hydrochloride) Oral Tablet 15 MG (Oxycodone HCl) Give 1 mg by mouth every 4 hours as needed forpain 90mg Max [maximum] daily amount.On 1/13/26, a physician order was started for oxyCODONE HCl Oral Tablet 15 MG (Oxycodone HCl) Give 1 mg by mouth every 4 hours as…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-28 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that each resident who was given a psychotropic drug had adequate monitoring of that drug. Specifically, for 1 out of 42 sampled residents, a resident receiving an antidepressant for insomnia did not have hours of sleep monitored. Resident identifier: 60.Findings included:Resident 60 was admitted to the facility on [DATE] with diagnoses which included obstructive sleep apnea, anxiety disorder, and insomnia.A physician's order started on 5/21/26, documented, trazodone HCl [hydrochloride] Oral Tablet 50 MG [milligrams] (Trazodone HCl) Give 1 tablet by mouth at bedtime for sleep/anxiety. A physician's order started on 5/24/26, documented, Trazodone: Document # [number] of hours of sleep per shift two times a day.The May 2026 Treatment Administration Record (TAR) was reviewed. The number of hours of sleep were not documented on 5/24/26 and 5/25/26.On 5/28/26 at 7:59 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-28 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that the facility did not ensure that in response to allegations of abuse and neglect the facility must have evidence that all alleged violations were thoroughly investigated. Specifically, for 1 of 42 residents sampled, the facility did not have evidence that an alleged violation of neglect was investigated. Resident identifier: 66.Findings included:Resident 66 was admitted to the facility on [DATE] with diagnoses which included periprosthetic fracture of left hip joint, difficulty in walking, and muscle wasting and atrophy On 7/23/25 at 3:12 PM, the facility reported that on 7/22/25 at 10:30 AM, resident 66 was found on the floor after sustaining a fall. Resident 66's spouse had just left the room when a crash was heard by her and the staff. Resident 66 was transferred to the emergency room (ER) for sutures to a bleeding laceration. Resident 66's medical records were reviewed.On 7/22/25 at 7:29 PM, resident 66's Nurses Note documented, At approximately…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-28 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that the facility did not document in the resident's medical record the information that was provided to the receiving provider which must include a minimum of the practitioner responsible for the care of the resident; the resident representative contact information; advanced directive information; comprehensive care plan; a copy of the resident discharge summary; and all necessary information to ensure a safe and effective transition of care. Specifically, for 1 of 42 sampled residents, the facility did not document in the resident's medical record the information conveyed to the receiving provider when the resident was transferred to the Emergency Room. Resident identifier: 48.Findings included:Resident 48 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, sepsis, adult failure to thrive, cataracts, vertigo, hypertension, and supraventricular tachycardia.Resident 48's medical records were reviewed.On 3/25/26 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · D2026-05-28 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined that the facility did not provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless the individual's clinical condition demonstrated that such diminution was unavoidable. Specifically, for 1 of 42 residents sampled, the facility did not provide dining assistance for a resident that required such assistance and other residents were observed feeding the resident. Resident identifiers: 8 and 11.Findings included:Resident 11 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia, hallucinations, Parkinson's disease, and Alzheimer's disease.Review of resident 11's records was completed on 5/26/26 through 5/28/26.A Minimum Data Set (MDS) assessment dated [DATE] revealed that resident 11 had a Brief Interview of Mental Status (BIMS) score of 09 which indicated moderate cognitive impairment. The MDS also indicated that resident 11…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-28 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, for 1 of 42 residents sampled, the resident developed skin breakdown at the facility and interventions were ordered but not implemented. Resident identifier: 54.Findings included:Resident 54 was admitted to the facility on [DATE] with diagnoses which included fracture of right lower leg, orthopedic aftercare, type 2 diabetes mellitus, and muscle wasting and atrophy. On 5/26/26 at 9:38 AM, an interview was conducted with resident 54. Resident 54 stated that he had a sore on his bottom and it developed after he was admitted to the facility. Resident 54 stated that he applied cream to the area and he believed it developed due to sitting on it too much. Resident 54 stated that now they had him wearing a brief, and it caused rashes.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-28 · 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 the resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; for excessive duration; without adequate monitoring; in the presence of adverse consequences; or any combination of the above. Specifically, for 1 out of 42 sampled residents, the facility did not monitor the resident's insulin administration through his insulin pump system. Resident identifier: 54.Findings included: Resident 54 was admitted to the facility on [DATE] with diagnoses which included fracture of right lower leg, orthopedic aftercare, type 2 diabetes mellitus, and muscle wasting and atrophy. On 5/26/26 at 9:47 AM, an interview was conducted with resident 54. Resident 54 stated that his blood sugars at the facility were terrible. Resident 54 stated that his insulin infused through the Omnipod insulin pump. Resident 54 stated that the insulin pump lasted 3 days before it needed to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-28 · tag F0800 — isolatedProvide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary 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 that the facility did not provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Specifically, for 1 out of 42 sampled residents, the resident was not provided the dietary preferences as requested to help manage his diabetes. Resident identifier: 54.Finding included: Resident 54 was admitted to the facility on [DATE] with diagnoses which included fracture of right lower leg, orthopedic aftercare, type 2 diabetes mellitus, and muscle wasting and atrophy.On 5/26/26 at 9:47 AM, an interview was conducted with resident 54. Resident 54 stated that the facility did not provide him with a diabetic diet. Resident 54 stated that for breakfast they gave him 2 packets of oatmeal and he could not eat it because it had too much sugar. Resident 54 stated that he had informed the staff of his concerns with his food but…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-05-28 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement 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 that the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor antibiotic use. Specifically, for 2 out of 42 sampled residents, the facility prescribed antibiotic therapy to treat a Urinary Tract Infection (UTI) without obtaining a culture and sensitivity report to identify the organism and the antibiotic that organism was susceptible to. Resident identifier: 74 and 75.Findings included:1. Resident 74 was admitted to the facility on [DATE] with diagnoses which included methicillin susceptible staphylococcus aureus infection classified elsewhere and a urinary tract infection. On 3/4/26, resident 74 had a urinalysis with culture obtained. The urinalysis documented an abnormal value of urine nitrite (positive) and a trace amount of blood in the urine. The urinalysis documented no to culture indicated. The lab result form had a hand written order for Macrobid 100 milligram (mg) by mouth two…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-28 · 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 it was determined that the facility did not ensure that residents were offered the pneumococcal immunization unless medically contraindicated or declined. Specifically, for 1 out of 5 residents sampled, the resident signed the pneumococcal immunization form but the form did not indicate an administration or refusal of the vaccine. Resident identifier: 12.Findings included:Resident 12 was admitted to the facility on [DATE] with diagnoses which included aftercare following joint replacement surgery and presence of left artificial knee joint.Resident 12's medical records were reviewed. Resident 12 had a signed copy of the Pneumococcal Vaccine Consent form. The form did not contain a date, a consent for administration of the vaccine, or a declination of the vaccine. On 5/28/26 at 10:12 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that they did not administer the Pneumococcal vaccine to resident 12 and there was no way to determine if she…
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 · E2025-01-08 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement 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 4 of 22 sampled residents, that the facility did not ensure that the resident's drug regimen was free from unnecessary psychotropic drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use. Specifically, resident's psychotropic medications did not have a corresponding diagnosis or adequate indication for use. Resident identifier: 30, 83, 136 and 139. Findings included: 1. Resident 30 was admitted to the facility on [DATE] and passed away on 11/4/24 with diagnoses which included diverticulitis, need for assistance with personal care, muscle wasting, heart failure, chronic obstructive pulmonary disease and chronic respiratory failure. Resident 30's medical record was reviewed 1/6/25 through 1/8/25. A physician's note dated 11/3/24 revealed resident 30 had a history of diverticulosis, chest was clear, cardiac was regular, abdomen was benign…
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 before2025-01-08 · 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 and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, cellular phones and a bluetooth speaker were stored on a drying rack used to store clean dishes and utensils in the kitchen, foods were stored inappropriately in the kitchen freezer, and staff did not serve food in a sanitary manner. Findings Include: On 1/6/24 at 9:25 AM, an observation was made of the drying rack next to the dish machine in the kitchen. On one of the shelves there was a bluetooth speaker and two cellphones with charging cords stored on the drying rack. The drying racks also had clean dishes and cooking utensils stored on the racks. On 1/6/24 at 9:32 AM, an observation was made of the kitchen freezer. There was a box of frozen blueberries open to the air. The blueberries were stored inside a plastic bag inside the box. Both the bag and box were open to air. There was a box of coconut cream pies and a box of breadsticks stored on the floor of the freezer. On 1/8/25…
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.
- Potential for harm · Ecited before2025-01-08 · tag F0880 — failed to prevent and control infections — patternProvide 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 1 of 22 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, a licensed nurse was observed to touch medication with contaminated gloves, alcohol swabs were placed on unclean surfaces prior to use, and used lancets were not disposed of in the sharps container. Resident identifier 85. Findings included: Resident 85 was admitted to the facility on [DATE] with diagnoses which included displaced intertrochanteric fracture of left femur, encounter for orthopedic aftercare, muscle wasting and atrophy of the right and left shoulder, hypothyroidism, type 2 diabetes mellitus, hypomagnesemia, generalized anxiety disorder, insomnia, chronic pain, encephalopathy, and hypertension. On 1/6/25 through 1/8/25, resident 85's medical records…
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 before2025-01-08 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 22 sampled resident, that the facility did not ensure residents received treatment and care in accordance with professional standards of practice. Specifically, there was no documentation regarding a resident experiencing a change in condition prior to passing away. Resident identifier: 30. Findings included: Resident 30 was admitted to the facility on [DATE] and passed away on 11/4/24 with diagnoses which included diverticulitis, need for assistance with personal care, muscle wasting, heart failure, chronic obstructive pulmonary disease and chronic respiratory failure. Resident 30's medical record was reviewed 1/6/25 through 1/8/25. A physician's note dated 11/3/24 revealed resident 30 had a history of diverticulosis. The assessment documented that resident 30's chest was clear, cardiac was regular, abdomen was benign and vital signs were stable. The assessment and plan further revealed On going support care, medication management. Antibiotics…
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 · D2025-01-08 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 1 of 22 sampled residents, that the facility did not ensure that a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, a resident was admitted with pressure ulcers [PU] and treatments were not provided according to physician orders. In addition, physician's orders were not the same as the wound clinic orders. Resident identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included acute osteomyelitis of right ankle and foot, diastolic heart failure, diabetes mellitus, pressure ulcer of right heel stage 3, severe-protein calorie malnutrition, acute respiratory failure with hypoxia, and severe sepsis. On 1/6/25 at 2:10 PM, an interview was conducted with resident 9. Resident 9 stated he had sores on his…
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 · D2025-01-08 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 1 of 22 sampled resident, the facility did not ensure that pain management was provided to residents who required services consistent with professional standards of practice and the comprehensive person-centered care plan and the resident's goals and preferences. Specifically, a resident complained of uncontrolled pain and the facility had not reassessed her pain. Resident identifier: 83. Findings include: Resident 83 was admitted to the facility on [DATE] with diagnoses which included displaced fracture of greater trochanter of right femur, pain, need for assistance with personal care, diabetes mellitus, fibromyalgia, depression, anxiety and heart failure. On 1/6/25 at 12:13 PM, an interview was conducted with resident 83. Resident 83 stated she had been at the facility since before Christmas and was experiencing pain in the right leg. Resident 83 stated she had lots and lots of pain in the leg and Doesn't like to have pain in the leg and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-08 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that for 1 of 22 residents, that the facility did not ensure that the resident's drug regimen was adequately monitored. Specifically, a resident was administered a medication used to treat hypertension when the resident's blood pressure was outside of parameters set by a physician's order. Resident Identifier: 24 Findings Include: Resident 24 was admitted [DATE] with diagnoses which included intertrochanteric fracture of left femur, fracture of the lower end of the left radius, essential (primary) hypertension, and hyperlipidemia. Resident 24's medical record was reviewed from 1/6/25 through 1/8/25. Resident 24's physician orders and Medication Administration Record (MAR) were reviewed from December 2024 through January 2025. Resident 24 had a physician's order that stated, Metoprolol Tartrate Oral Tablet 25 MG [milligrams] Give 0.5 tablet by mouth two times a day for HTN [hypertension] hold for SBP [systolic blood pressure] < [less than] 100 or apical…
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 before2025-01-08 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement 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 22 sampled residents, that the facility did not ensure that its antibiotic stewardship program included antibiotic use protocols and a system to monitor antibiotic use. Specifically, a resident was prescribed a course of antibiotic therapy for a urinary tract infection without a culture and sensitivity report to verify that the organism was susceptible to the antibiotics ordered. Resident identifier 7. Findings included: Resident 7 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, urinary tract infection, type 2 diabetes mellitus, congestive heart failure, chronic kidney disease, benign prostatic hyperplasia, pain, and presence of urogenital implants. On 1/8/25, resident 7's medical records were reviewed. On 12/4/24, resident 7 had an order initiated for Bactrim Tablet 800-160 milligram (mg) (Sulfamethoxazole-Trimethoprim), give 1 tablet by mouth in the morning for urinary tract infection (UTI) for 5…
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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CHP TRS HOLDING INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 10/01/2014 |
| CAPITAL SENIOR LIVING CORPORATION | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/11/2026 |
| SSL SPARTI LLC | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 03/11/2026 |
| SSL SPARTI PROPERTY HOLDINGS INC. | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | — | since 03/11/2026 |
| HERRICK, CHAD | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 12/28/2022 |
| PORM, KRISTIN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/17/2015 |
| BAILEY, TABITHA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 03/11/2026 |
| RIBAR, BRANDON | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 03/11/2026 |
| COBER, TIMOTHY | Individual | CORPORATE OFFICER | — | since 03/11/2026 |
| DETZ, KEVIN | Individual | CORPORATE OFFICER | — | since 03/11/2026 |
| BEUS, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 07/01/2015 |
| LANGHORST, JODI | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2025 |
| LEVEE, KATHLEEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/01/2020 |
| WALKER, KRISTIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/15/2016 |
| GENERATIONS, L.L.C | Organization | ADP OF THE SNF | — | since 11/20/2014 |
CMS files one row per role, so the 31 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
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
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
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.
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 465174. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-28, 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.