Sunshine Terrace Skilled Nursing
248 West 300 North, Logan, UT 84321 · Government - Hospital district · 172 certified beds · (435) 752-0411 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- 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
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (1/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — 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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 2 to 1 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 | 3.3% | 11.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.6% | 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 | 7.2% | 1.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 6.3% | 16.5% | 6.5% | typical |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.9% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 13.4% | 15.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 34.9% | 25.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 95.2% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.3% | 3.9% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 26.4% | 21.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.8% | 14.2% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 3.0% | 0.9% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 40.6% | 91.0% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 23.2% | 16.5% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 21.5% | 11.6% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.75 | 1.25 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.28 | 1.43 | 1.80 | better |
§ 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.
Met the expected recovery: 67.9% 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 28 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.09 therapist hours per resident per day in 2026Q1 — more than 5% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 67.9% | 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 | 50.0% | 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 | 75.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 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 | 2.7% | 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 | 0.0% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.65 | 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 172 beds and averages 66.4 residents a day — about 39% occupied, or roughly 106 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Weekend coverage: total nurse staffing is 3.66 hrs/resident/day on weekends vs 4.22 on weekdays — 13% thinner on weekends. RN hours go from 1.36 to 1.16 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 47% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.
- Immediate jeopardy · Lcited before2026-04-13 · 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, 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, the walk-in refrigerator temperature was above 41 degrees Fahrenheit and food was stored in the danger zone. The food temperatures were above 41 degrees. This was cited at an Immediate Jeopardy (IJ). In addition, there were opened and undated food items in the walk-in refrigerator, freezer, and dry storage. Dietary staff were observed during lunch tray line service to touch food and other surfaces. NOTICE: Notice of the Immediate Jeopardy was given verbally to the Administrator (ADM), Dietary Manager (DM), and Director of Nursing (DON) on 4/6/26 at 10:31 AM. At that time, the ADM, DM, and DON were informed of findings of Immediate Jeopardy pertaining to F812 and were asked to develop an immediate plan to ensure that residents of the facility were free from food that had been stored, prepared,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2026-04-13 · 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 3 out of 32 residents, the facility did not provide a resident additional treatment for constipation which resulted in hospitalization for a bowel obstruction; a resident with Moisture Associated Skin Damage (MASD) did not have their wound evaluated by a wound care provider and received wound care without a physician order; and a resident with open wounds on their buttocks did not have wound prevention or skin assessments completed weekly as ordered. Resident identifiers: 3, 28, and 63. Findings included: 1. Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included cerebral infarction, pseudobulbar affect, epilepsy, chronic pain, Parkinsonism, type II diabetes mellitus,…
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 · E2026-04-13 · tag F0605 — failed to not use drugs as a restraint — patternPrevent 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 it was determined that the facility did not ensure that each resident who was given a psychotropic drug had an adequate indication for use of the medication; that psychotropic drugs received a gradual dose reduction and behavioral interventions, unless clinically contraindicated; as needed (PRN) orders for psychotropic drugs were limited to 14 days unless the practitioner documented a clinical rationale to extend beyond 14 days with a duration of use for the order; and PRN orders for anti-psychotics were limited to 14 days and cannot be renewed unless the attending physician evaluated the resident for the appropriateness of the medication. Specifically, for 5 out of 32 sampled residents, the facility did not document an adequate indication of use for Seroquel and Haldol; did not have monitoring for episodes of behavior with non-pharmacological behavioral interventions; did not have monitoring for adverse side effects (ASE) of psychotropic medications; did not have a gradual…
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 before2026-04-13 · 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, observation, and record review, the facility did not ensure that allegations of abuse and neglect were reported immediately to the State Survey Agency (SSA) and other agencies. Specifically, for 4 of 32 sampled residents, the facility did not report allegations of abuse to Adult Protective Services (APS) and the facility did not report when a resident eloped from the facility to the SSA. Resident Identifier: 3, 41, 47 and 58. Findings included: 1. Resident 41 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's, chronic venous hypertension, and dementia. An incident report form submitted to the SSA revealed on 2/17/26 at 10:00 AM, The resident was assessed promptly by the attending nurse following identification of the contusion. The report documented multiple that possible causes were being evaluated. The resident will continue to be closely monitored and a follow-up report will be submitted upon completion of the diagnostic work up and further investigation…
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 · E2026-04-13 · tag F0610 — failed to investigate and act on abuse reports — patternRespond 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, the facility did not have evidence of a thorough investigation in response to allegations of abuse, neglect, exploitation, or mistreatment. Specifically, for 4 of 32 sampled residents, there were no thorough investigations into bruising on residents with dementia, Certified Nursing Assistants (CNA)'s being rough during a brief change and a resident eloping from the facility. Resident identifiers: 3, 41, 58, 72 Findings included: 1. Resident 41 was admitted to the facility on [DATE] with diagnosis of Alzheimer's, chronic venous hypertension, and dementia. An incident report form submitted to the State Survey Agency (SSA) revealed on 2/17/26 at 10:00 AM, The resident was assessed promptly by the attending nurse following identification of the contusion. The report documented multiple that multiple possible causes were being evaluated. The resident will continue to be closely monitored and a follow-up report will be submitted upon completion of the diagnostic work up 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 · E2026-04-13 · tag F0628 — patternProvide 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, the facility did not ensure that when they transferred a resident that it was documented in the resident's medical record and that the information contained the contact information of the practitioner responsible for the care of the resident; resident representative information; Advanced Directive information; all special instructions for ongoing care; comprehensive care plan goals; and all other necessary information to ensure a safe and effective transition of care. Specifically, for 3 of 32 sampled residents, the facility did not document in the residents' medical record the information that was given to the receiving provider, notify the Ombudsman, and provide the bedhold policy when residents were transferred to a hospital. Resident identifier: 3, 6, and 50. Findings included: 1. Resident 50 was admitted to the facility on [DATE] and readmitted after a hospital stay on 1/24/26 with diagnoses, which included but were not limited to, fluid overload. On 1/21/26 at 7:04 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-13 · 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, for 2 of 32 sampled residents, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident eloped from the facility after being identified as wandering prior and the same resident sustained falls with no new interventions. In addition, another resident eloped from the facility. Resident identifiers: 47 and 72. Findings included: 1. Resident 47 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, arthritis, pain, psychotic disorder with hallucinations, major depressive disorder, and dementia with psychotic disturbance. FALLS On 4/8/26 at 10:19 AM, a concurrent observation and interview were made of resident 47. Resident 47's door was shut , and the resident was observed to be laying in bed with his walker about 2 steps away from his bed. Resident 47 stated if he needed help he used the button. Resident 47's call light was wrapped around the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-04-13 · 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, 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 for 3 out of 32 sampled residents, Enhanced Barrier Precautions (EBP) was not implemented for a resident with an indwelling medical device. Additionally, hand hygiene was not performed during wound care for a resident and there was cross-contamination during dining when a Certified Nursing Assistant (CNA) touched a chair and then a resident's food. Resident identifiers: 6, 17, and 28. Findings Included: 1. Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included end stage renal disease, dependence on renal dialysis, and type 2 diabetes with diabetic chronic kidney disease. Resident 6's medical record was reviewed 4/6/26 through 4/13/26. On 4/6/26 at 12:23 PM, a concurrent…
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 before2026-04-13 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not ensure that the resident right to self-administer medications was clinically appropriate and safe. Specifically for 2 out of 32 sampled residents, residents were observed to have medications in their rooms and were not evaluated to determine if they were safe to self-administer medications. Resident identifiers: 6 and 28. Findings included: 1. Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, acute posthemorrhagic anemia, constipation, and gastrointestinal hemorrhage. Resident 6's medical record was reviewed 4/6/26 through 4/13/26. On 4/6/26 at 12:19 PM, an observation was made of an opened bottle of Pepto-Bismol on resident 6's dresser. On 4/7/26 at 9:04 AM, an interview was conducted with resident 6. Resident 6 stated that he had administered Pepto-Bismol to himself for an upset stomach. Resident 6 stated that he last had Pepto Bismol about one week ago. It should be noted that no…
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 before2026-04-13 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 maintain evidence demonstrating the results of all grievances for a period of no less than three years from the issuance of the grievance decision. Specifically, for 1 out of 32 sampled residents, a resident's family member reported a missing purse, wallet, and glasses, but the facility did not document a prompt resolution or follow-up. Resident identifier: 5. Findings included: Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included heart failure, Sjogren's syndrome, and Non-Hodgkin lymphoma.On 4/6/26 at 12:19 PM, an interview was conducted with resident 5's family member. The family member stated that resident 5 lost her purse, driver's license, and credit cards when she was first admitted to the facility. The family member stated that facility staff never located the purse. On 4/6/26 at 8:46 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that if a resident notified…
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 · D2026-04-13 · 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 observation, interview and record review, for 1 of 32 sampled residents, the facility did not develop and implement comprehensive person-centered care plans for each resident. Specifically, a resident's care plan was not updated with interventions after each fall. Resident identifier: 47. Findings included: Resident 47 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, arthritis, pain, psychotic disorder with hallucinations, major depressive disorder, and dementia with psychotic disturbance. On 4/8/26 at 10:19 AM, a concurrent interview and observation were made of resident 47. Resident 47's door was shut. Resident 47 was observed to be laying in bed with his walker about 2 steps away from his bed. Resident 47 stated if he needed help he used the button. Resident 47's call light was wrapped around the head board and not within reach. Resident 47 was observed to try and find the call light but he was unable to find the call light. At 10:43 AM, the call light…
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 · D2026-04-13 · 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 interview and record review it was determined that the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. Specifically, for 1 out of 32 sampled residents, the facility did not address a resident's pain when Semi-Effective pain control was reported by the resident. Resident identifier: 63. Findings included: Resident 63 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included chronic pain, peripheral vascular disease, chronic kidney disease, major depressive disorder, and generalized anxiety disorder. On 4/07/26 at 9:17 AM, an interview was conducted with resident 63. Resident 63 stated she had pain in the right leg and her back. Resident 63 stated that they gave her pain medications and it somewhat helped. It calms down the pain, so it's not as intense, but doesn't take it…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 17 citations
- Potential for harm · D2026-04-13 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 32 sampled residents, a resident receiving dialysis did not have a physician's order for dialysis and communication notes with the dialysis center were missing. In addition, the staff were not monitoring the dialysis fistula and there were no physician orders to monitor the dialysis fistula. Resident identifier: 50. Findings included: Resident 50 was admitted to the facility on [DATE] and readmitted after a hospital stay on 1/24/26 with diagnoses, which included but were not limited to, fluid overload, unspecified, end stage renal disease, chronic diastolic (congestive) heart failure, hypotension, unspecified, hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic…
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 · D2026-04-13 · tag F0728 — failed to protect against nurse-aide misconduct — isolatedEnsure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review the facility did not ensure that individuals working in the facility as a nurse aide had completed a training and competency evaluation program within 4 months from date of hire. Specifically, for 1 out of 5 sampled staff members, the facility had employed a Nurse Aide since May of 2025 without them having completed their certification course. Staff identifier: Nurse Aide (NA) 1. Findings included: On 4/13/26, NA 1's personnel file was reviewed. NA 1's date of hire was 5/19/25. NA 1 did not have verification of a completed nurse aide competency and certification course on file. On 4/13/26 at 11:47 AM, an interview was conducted with Human Resources (HR) 1. HR 1 stated that upon hire they provided education to the NA on where they could obtain their certification and how they could be reimbursed by the facility. HR 1 stated that NA 1 was hired in May 2025 and was still working without his certification. HR 1 stated that upon hire NA 1 signed a form acknowledging that he was provided this education and was required to obtain his certification…
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 · D2026-04-13 · 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 was any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicated the dose should be reduced or discontinued; or any combination of the above. Specifically, for 2 out of 32 sampled residents, the facility did not monitor residents' pain management for non-pharmacological interventions and adverse side effects. Resident identifiers: 50 and 58. Findings included: 1. Resident 58 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia, insomnia, fracture of right femur, and pain. Resident 58's physician orders included: Tramadol - Schedule IV tablet; 50 milligrams (mg) oral every 6 hours as needed (PRN). The order was initiated on 10/29/25.…
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 · D2026-04-13 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined that the facility did not ensure that nurse aides received in-service training for continued competency of no less than 12 hours per year and included dementia management and abuse prevention training. Specifically, for 2 out of 5 sampled employees, the nurse aides did not receive 12 hours per year of continued competency training. Staff identifiers: Certified Nurse Assistant (CNA)1 and Nurse Assistant (NA) 1. Findings included: On 4/13/26, CNA 1 and NA 1's personnel files were reviewed. CNA 1 had a date of hire of 11/10/25, and NA 1 had a date of hire of 5/19/25. CNA 1 and NA 1 did not have any evidence of continued competency training that was at least 12 hours per year. On 4/13/26, Human Resources (HR) 1 provided a staff training schedule for the 5 sampled employee files. The schedule documented that CNA 1 had not received any of the 3 in-service training opportunities since date of hire and NA 1 had not received any of the 6 in-service training opportunities since date of hire. Additionally, none of the documented training…
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 before2024-02-22 · 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 facility policy review, the facility failed to adhere to professional standards for food safety when preparing, storing, and distributing food to residents who were served food from the facility's kitchen. This failure had the potential to affect 50 of 50 residents who received nutrition from the kitchen. Findings included: Review of a facility policy titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised in November 2022, revealed, Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Under a Policy Interpretation and Implementation section, the policy noted 1. All employees who handle, prepare or serve food are trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. Under a Hand Washing/Hand Hygiene section, the policy noted 6. Employees must wash their hands: a. after personal body…
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 before2024-02-22 · tag F0585 — failed to handle grievances — patternHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and facility policy review, the facility failed to ensure the provision of the right to file grievances anonymously. This failure had the potential to impact facility residents who were able to execute their right to file grievances. Findings included: A review of a facility policy titled Grievances/Complaints, Filing, revised in April 2017, revealed, 5. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously. The policy revealed, 13. If the grievance was filed anonymously, the grievance officer will inform the resident that a grievance has been anonymously filed on his or her behalf and the steps that will be taken to investigate the grievance(s) and report the findings. During an interview on 02/22/2024 at 9:35 AM, Social Worker (SW) #5 stated she was the grievance official, and when residents or family members wanted to file a grievance, they would come to her. SW #5 stated she would be notified if a resident or family member wished to file a grievance, and she conducted the investigation, resolved the grievance, 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 · Ecited before2024-02-22 · 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, record review, and facility document and policy review, the facility failed to report allegations of abuse within two hours for 2 (Resident #28 and Resident #39) of 2 residents reviewed for abuse prohibition. Findings included: Review of a facility policy titled, Abuse Investigating and Reporting revised in 12/2016, revealed, All reports of abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies and Reporting 2. Suspected abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported within two hours. Review of a facility policy titled, Grievances/Complaints -Staff Responsibility, revised in 10/2017, revealed, Staff members are encouraged to guide residents about where and how to file a grievance and/or complaint when the resident believes that his/her rights have been violated and 4.…
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 before2024-02-22 · 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 2. A review of a facility policy titled, Handwashing/Hand Hygiene, revised in October 2023, revealed, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. The policy revealed, 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Under a section titled Indications for Hand Hygiene, the policy noted, in part, 1. Hand hygiene is indicated: a. immediately before touching a resident; c. after contact with blood, body [sic] fluids, or contaminated surfaces; d. after touching a resident; e. after touching the resident's environment; and g. immediately after glove removal. Further review revealed 5. The use of gloves does not replace hand washing/hand hygiene. During observations on 02/20/2024 starting at 8:58 AM, Housekeeper #3 traveled down the Wing 2 hall with blue gloves on both hands, pushing a large laundry bin on wheels. Housekeeper #3 entered…
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 before2024-02-22 · 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, record review, and facility policy review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 (Resident #50 and Resident #3) of 7 residents. Specifically, the facility failed to provide wound care per physician orders for Resident #50 and failed to verify an order for antibiotic use with the ordering physician for Resident #3. Findings included: 1. Review of a facility policy titled, Wound Care, revised in 10/2010, revealed The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Under a Documentation section, the policy identified information that should be recorded in the resident's medical record, including 2. The date and time the wound care was given. A review of Resident #50's Detailed Summary revealed the facility originally admitted the resident on 01/03/2024 with diagnoses including venous insufficiency, peripheral vascular disease, and history of ulcer formation on…
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 before2022-05-19 · 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 25 sample residents, that the facility did not ensure the residents' environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents. Specifically, the facility did not ensure that a gas-powered fireplace in the residents' common area of the dementia unit was set up in such a way that ensured the protection of residents from possible burns. Resident identifiers: 31, 37, and 49. Findings include: On 5/16/22 at 10:15 AM, a continual observation was made of resident 37 and resident 49 wheeling themselves close to the fireplace and leaning forward in their wheelchairs with outstretched hands open towards the fireplace. Resident 37 and resident 49 both remained in this position until 10:39 AM. No staff were present in the common area during this period of time. At 10:40 AM Registered Nurse (RN) 1 entered the common area and wheeled both residents back from the fireplace by…
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 · E2022-05-19 · tag F0811 — patternEnsure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
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 observation, the facility did not ensure that 3 of 25 sample residents were provided assistance with dining by a feeding assistant who had completed a state-approved training course before feeding residents. Specifically, music therapists and a community volunteer were feeding residents without training or supervision. Resident identifier: 2, 21, and 31. Findings include: On 5/16/22 at 11:25 AM an observation was made of Music Therapist (MT) 1 feeding resident 21 and MT 2 feeding Resident 2. 1. Resident 2 was admitted to the facility on [DATE] with diagnoses that included dementia, hypoxemia, hypolipidemia, insomnia, and muscle weakness. Resident 2's medical record was reviewed on 5/18/22. Resident 2's annual Minimum Data Set (MDS) dated [DATE] revealed resident 2 required 1 person assistance with supervision for eating. A care plan dated 4/17/22 revealed resident 2 was at nutritional risk related to weight loss. The goal was to meet the resident's needs and stabilize weight. 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 · Ecited before2022-05-19 · 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 distribute and serve food in accordance with the professional standards of food service safety. Specifically, food items in a walk-in freezer were open to air and food items in the walk-in refrigerator were not dated or were past the use by period, the log on 2 refrigerators revealed the temperature was above a safe storage temperature, and there were chipped tiles in the food preparation area. Findings include: 1. On 5/16/22 at 10:21 AM, an initial tour of the kitchen was conducted. The following was observed: a. A box of tilapia fish, in the walk-in freezer, that was unsealed and open to air. b. The reach-in freezer had frozen burritos and corn dogs unsealed and open to air. c. There were several chipped tiles on the kitchen floor in the food preparation area. d. The inside the walk-in refrigerator #2 was 45 degrees Fahrenheit. e. The reach-in refrigerator #3 was 40 degrees Fahrenheit. On 5/18/22 at 9:08 AM, an interview was conducted with Dietary Aide (DA) 1. DA 1 stated that she documented the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-05-19 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review the facility did not ensure that medical records were complete and accurate for 4 of 25 sampled residents. Specifically, resident Provider Order for Life-Sustaining Treatment (POLST) form did not match in their electronic medical record with the one in the paper chart and resident documents were in the wrong resident's medical record. Resident identifiers: 25, 39, 32, 8, and 38. Findings include: 1. Resident 25 was admitted to the facility on [DATE] with diagnoses which included non-traumatic brain dysfunction, anemia, hypertension, and diabetes mellitus. Resident 25's medical record was reviewed on [DATE]. Resident 25's electronic medical record revealed Do Attempt CPR (Cardiopulmonary resuscitation) for Pre-Arrest Emergency; however DNR for Full-Arrest Emergency. A POLST form in the paper medical record at the nurses station dated [DATE] revealed resident 25 desired under DNR with CPR. Resident 25 desired limited additional interventions which included Treating medical conditions while…
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 before2022-05-19 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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 25 sample residents, that the facility did not ensure that the interdisciplinary team (IDT) had evaluated and determined that the resident's right to self-administer medications was clinically appropriate. Specifically, a resident was observed to have medication at her bedside without staff supervision and had not been assessed to determine if she was able to self-administer medication. Resident identifier: 10 Findings included: Resident 10 was admitted to the facility on [DATE] with diagnoses which included dysphagia, generalized anxiety disorder, weakness, gastro-esophageal reflux disease, hypertension, and hypoxemia. On 5/16/22 at 11:19 AM, an interview was conducted with resident 10. An observation was made of 4 medications in a medicine cup on the bedside table next to the resident. Resident 10 stated she received those medications in the morning but had to wait until she ate or else, she choked on them. Resident 10 stated she 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 · D2022-05-19 · 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 for 1 of 25 sample residents, the facility did not provide the necessary services to maintain or improve the residents' activities of daily living. Specifically, a resident did not receive assistance with eating. Resident identifier: 48. Findings include: Resident 48 was admitted to the facility on [DATE] with diagnoses that included non-traumatic brain dysfunction, dementia, malnutrition, depression, and psychotic disorder. On 5/16/22 at 11:31 AM until 12:43 PM, an observation was made of resident 48 in the dining room eating her meal. Resident 48 had pureed foods that consisted of mashed potatoes and gravy, a green vegetable, pureed bread in a bowl, an orange dessert, a small glass of water and orange juice. Resident 48 was observed to eat her pureed foods with a fork. Resident 48 was observed to place the end of a straw into her pureed food and place the straw in her mouth. There was no observation of staff assisting, cueing or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined that the facility did not maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight, unless the resident's clinical condition demonstrated that this was not possible. Specifically, a resident that lost weight and nutritional interventions developed were not implemented. Resident identifier: 48. Findings include: Resident 48 was admitted to the facility on [DATE] with diagnoses that included non-traumatic brain dysfunction, dementia, malnutrition, depression, and psychotic disorder. On 5/16/22 at 11:31 AM until 12:43 PM, an observation was made of resident 48 in the dining room eating her meal. Resident 48 had pureed foods that consisted of mashed potatoes and gravy, a green vegetable, pureed bread in a bowl, an orange dessert, a small glass of water and orange juice. Resident 48 was observed to eat her pureed foods with a fork. Resident 48 was observed to place the end of a straw into her pureed…
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 · D2022-05-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 2 of 25 sample residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice. Specifically, residents with oxygen did not have their tubing and the humidifier changed. Resident identifiers: 8 and 32. Findings include: 1. Resident 8 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, esophageal obstruction, hypothyroidism, cough and anxiety. On 5/16/22 at 10:51 AM, an interview and observation was conducted with resident 8. An observation was made of resident 8's oxygen tubing not labeled. Resident 8 stated their oxygen tubing was changed whenever they request it. Resident 8 stated that their oxygen tubing lasted them a couple of months before it was changed. Resident 8 also stated that the tubing they currently had was new because it was changed that week. Resident 8 stated they were on oxygen because…
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. 1 Medicare payment denial on record.
- Medicare payment denial — starting 2026-05-15 for 7 days
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BARTON, MICHELLE | Individual | CORPORATE OFFICER | since 10/02/2022 |
| ERICKSON, BRYAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | since 10/02/2022 |
| SUNSHINE TERRACE FOUNDATION, INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 10/02/2022 |
CMS files one row per role, so the 4 rows in the source record cover these 3 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.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 73% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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
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 465079. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-13, 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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