Canyonland Care Center
390 West Williams Way, Moab, UT 84532 · Government - County · 36 certified beds · (435) 719-4400 Medicaid only — no Medicare
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (22% vs 45% nationally) — better care continuity
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $11,193 in federal fines (most recent 2025-05-05)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.4% | 11.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.3% | 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 | 0.8% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.4% | 16.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 6.0% | 2.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 10.9% | 15.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.7% | 25.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.8% | 3.9% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.0% | 21.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.0% | 14.2% | 17.1% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.32 | 1.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 3.88 | 1.43 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Staffing
How full it usually is: this home is certified for 36 beds and averages 31.5 residents a day — about 88% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.96 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.95 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.28 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.62 hrs/resident/day on weekends vs 5.10 on weekdays — 9% thinner on weekends. RN hours go from 1.06 to 0.68 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 22% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
17 citations, most serious first. The 12 most serious are shown; the remaining 5 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-05-05 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 3 of 9 sampled residents, the facility failed to keep residents free from abuse. Specifically, a registered nurse interacted with a resident with unzipped and open pants and touched the resident under the blankets in the abdominal/pelvic area. Additionally, two other residents came forward after the incident with allegations of inappropriate interactions involving the same nurse. Resident identifiers: 1, 2, and 4. It was determined the provider's non-compliance with the requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to the State Operations Manual, Appendix PP, 483.12 Freedom from Abuse, Neglect, and Exploitation, F600, at a scope and severity of J. However, based on the facility's corrective actions and a review of its current compliance in this regulatory area, the deficiency was determined to be past noncompliance.…
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 before2022-08-18 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 18 sampled residents, the facility did not ensure the resident was free from physical abuse. Specifically, facility staff did not ensure that a resident, known to wander into other residents rooms, was prevented or redirected away from other resident rooms. As a result, another resident, angry by recurring intrusions into his private space, threw a plastic mug striking the uninvited resident on the head, causing a laceration. Resident identifiers: 9 and 27. Cross-refer to F675 regarding noncompliance associated with resident 27's Quality of Life. Findings include: Resident 27 was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, epilepsy, depression, and heart failure. Resident 9 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, glaucoma, anxiety disorder, dysphagia, and insomnia. On 8/17/22 at 11:26 AM, CNA 3 was interviewed. CNA 3 resident 27 did…
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 · D2025-11-05 · 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
Based on interview and record review, the facility failed to ensure the right to voice grievances to the facility without discrimination or reprisal. Specifically, for 3 out of 18 sampled residents the right to file grievances anonymously was not provided to the residents or representatives of the residents. Resident identifier: 29 [Note: Two resident identifiers were withheld to maintain anonymity.] Findings included: During the survey a confidential interview was conducted with a resident representative, Confidential Interviewee (CI) 1. CI 1 stated that the facility's management did not always address resident, family member, and nursing staff concerns, including the concerns brought up in resident council. CI 1 stated that it was normal for concerns to be briefly addressed before the situation returned to its prior condition. CI 1 stated that in order to report concerns they had to verbally inform facility management, and that they did not know how to address concerns about facility management because there was not a way to make anonymous concerns. During the survey a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-05 · 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 interview and record review it was determined, for 1 of 18 residents sampled, that the facility did not ensure residents were given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living. Specifically, a resident was not provided showers. Resident identifier: 3. Findings included: On 11/5/25 resident 3 was interviewed and stated she received hospice care but her showers were provided by the facility. Resident 3 stated she used to receive 3 showers a week but now she had only been getting 2 showers a week. Resident 3 stated she would like to get 3 showers a week and she had told the staff about her concern but nothing had changed. Resident 3's medical record was reviewed 11/3/25 through 11/5/25. Resident 3 was admitted to the facility on [DATE] with diagnoses which included corticobasal degeneration, malignant neoplasm of lung, depression, dementia, chronic pain and palliative care.A quarterly Minimum Data Set (MDS) dated [DATE] revealed…
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 · D2025-11-05 · 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 that for 1 of 18 sampled residents, that the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice. Specifically, the facility did not maintain documentation that a resident's primary care provider had been notified of a resident's change in condition. Resident Identifier: 34 Findings Included: Resident 34 was admitted [DATE], and discharged [DATE] with diagnoses including other frontotemporal neurocognitive disorder, personal history of transient ischemic attack and cerebral infarction without residual deficits, other recurrent depressive disorders, atrioventricular block first degree, age-related osteoporosis without current pathological fracture, hypothyroidism unspecified, essential (primary) hypertension, and hypokalemia. Resident 34's medical record was reviewed from 11/3/25 through 11/5/25. A progress note dated 1/15/25 at 10:51 PM stated, CNA's [sic] reported that resident had a LG…
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 · D2025-11-05 · 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 for 1 of 18 sampled residents the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise. Specifically, 1 resident experienced significant weight loss with interventions not put into place timely. Resident identifier: 2. Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included depression, dementia, osteomyelitis, muscle weakness, chronic congestive heart failure and atrial fibrillation. Resident 2's medical record was reviewed on 11/4/25. Resident 2 had a BIMS (Brief Interview for Mental Status) completed on 10/11/25 which was 5 out of 15 which indicated severe cognitive impairment. A social service note dated 10/10/25 revealed resident 2's physical capabilities were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-05 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, it was determined that the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles, under proper temperature controls and cautionary instructions, and the expiration date when applicable. Specifically, opened multi-dose pens of medications were not labeled with open dates. Findings included: On 11/5/25 at 10:25 AM, the Entrada Hall Medication Cart was inspected. The cart contained the following open medication pens; Novolog, with no open dateBasaglar, with no open date An interview was immediately conducted with Registered Nurse (RN) 2. RN 2 stated that the medication pens should have been labeled with open dates because the medications were only good for 28 days after they had been opened. On 11/5/25 at 12:20 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the medication pens should have been labeled with open dates. Additionally the DON stated that the medications were good for 28 days after opening. The DON stated that they 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 · D2025-11-05 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 out of 18 sampled residents, that the facility did not maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized. Specifically, hospice visit notes were not kept in the residents medical record. Resident identifier: 3.Findings included: Resident 3 was admitted to the facility on [DATE] with diagnoses which included corticobasal degeneration, malignant neoplasm of lung, depression, dementia, chronic pain and palliative care.On 11/5/25 resident 3 was interviewed and stated she received hospice care but her showers were provided by the facility. Resident 3 stated the hospice company came once a week. Resident 3's medical record was reviewed and weekly hospice notes were not located in the medical record. On 11/05/2025 at 8:52 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated they had new management take over the hospice company recently and 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 · D2024-07-11 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 allow the resident the right to formulate an advance directive. Specifically, for 1 out of 15 sampled residents, a resident that did not have a Physician Orders for Life-Sustaining Treatment (POLST) or Advance Directive was documented as do not resuscitate (DNR) in their medical record. Resident identifier: 19. Findings included: Resident 19 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia with psychotic disturbance, bradycardia, history of falling, diastolic heart failure, atrial fibrillation, type 2 diabetes mellitus, major depressive disorder, and chronic kidney disease. Resident 19's medical record was reviewed on 7/10/24. A physician's order dated 3/26/24, documented Order Summary: DNR. Advanced Directive Status: Verified By Medical Record Only. Order Type: Advanced Directive. An Advanced Directive or POLST were unable to be located in the medical record. A care plan Focus dated 4/2/24,…
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 before2024-07-11 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 all residents were free from abuse. Specifically, for 3 out of 15 sampled residents, allegations of abuse were not investigated to determine if abuse occurred when a staff member reported to management that a residents family member was observed to approach another resident and stand over a resident speaking loudly. In addition, another incident when residents yelled at each other and one resident threw a wet paper towel at another resident were not reported or investigated. Resident identifiers: 20, 22, 23, and 33. Findings included: On 7/10/24 at 9:41 AM, an observation was made of camera footage from the facility. The footage was from 4/22/24 at 10:57 AM. Resident 20 was observed standing next to resident 33 who was seated in a recliner with a family member sitting next to her. Resident 20 and 33 were observed to be talking but the audio was not clear to hear what they were talking about. Resident 20 was observed to pick up…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-07-11 · 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 residents were free from physical or chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms. Specifically, for 1 out of 15 sampled residents, a Registered Nurse (RN) gave a resident an unprescribed 25 milligram (mg) dose of Trazodone in addition to the resident's prescribed nightly dose of 25 mg of Trazodone. Resident Identifier: 17. Findings Included: Resident 17 was admitted to the facility on [DATE] with diagnoses including aspiration of fluid, respiratory failure, amnesia, nocturia, constipation, and occlusion and stenosis of right posterior cerebral artery. Resident 17's medical record was reviewed from 7/8/24 through 7/11/24. On 5/10/24, resident 17's quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 14, indicating no cognitive impairment. Resident 17's progress notes revealed the following: a. On 2/25/24 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 · D2024-07-11 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 observation, interview, and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately, but not later than two hours after the allegation was made. Specifically, for 3 out of 15 sampled residents, management did not report or investigate when a staff member reported to management that a residents family member was observed to approach another resident and stand over a resident speaking loudly. In addition, another incident when residents yelled at each other and one resident threw a wet paper towel at another resident were not reported or investigated. Resident identifiers: 20, 22, 23, and 33. Findings included: On 7/10/24 at 9:41 AM, an observation was made of camera footage from the facility. The footage was from 4/22/24 at 10:57 AM. Resident 20 was observed standing next to resident 33 who was seated in a recliner with a family member sitting next to her. Resident 20 and resident 33 were observed 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.
Show the remaining 5 citations
- Potential for harm · Dcited before2024-07-11 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, the facility did not keep the resident environment as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 15 sampled residents, a resident that choked on their food and required the Heimlich maneuver did not have interventions implemented to prevent future choking. Resident identifier: 31. Findings included: Resident 31 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, systolic congestive heart failure, left bundle branch block, cardiac arrhythmia, basal cell carcinoma of skin, schizophrenia, adult failure to thrive, and insomnia due to medical condition. On 7/9/24 at 1:55 PM, an interview was conducted with resident 31. Resident 31 stated that breakfast that morning was really good. Resident 31 stated that she coughed all the time on her food because she had problems with her lungs. Resident 31 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 · E2022-08-18 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 3 of 18 sample residents, that the facility assessments did not accurately reflect the resident's status. Specifically, a resident who wandered was not coded accurately on the Minimum Data Set (MDS) and was therefore not identified as a wanderer on the care plan. Resident identifiers: 5, 16 and 33. Findings include: 1. Resident 16 was admitted to the facility on [DATE] with diagnoses that include unspecified dementia without behavioral disturbance, insomnia, tubulo-interstitial nephritis, chronic obstructive pulmonary disease, hyperlipidemia, hypertension, and gastro-esophageal reflux disease. On 8/17/22 at 11:23 AM, an observation of resident 16 was made. Resident 16 was observed wandering in the hallway. At 11:47 AM, resident 16 wandering into an unsampled resident's room. Resident 16 was observed looking at the decorations for one minute, then exiting the room. No other residents were in the room. At 11:50 AM resident 16 was then…
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 · D2022-08-18 · 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 it was determined, for 1 of 18 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, a resident who wanders did not have a care plan to address wandering. Resident identifiers: 16 Findings include: 1. Resident 16 was admitted to the facility on [DATE] with diagnoses that include unspecified dementia without behavioral disturbance, insomnia, tubulo-interstitial nephritis, chronic obstructive pulmonary disease, hyperlipidemia, hypertension, and gastro-esophageal reflux disease. On 8/17/22 at 11:23 AM, an observation of resident 16 was made. Resident 16 was observed wandering in the hallway. At 11:47 AM, resident 16 wandering into another resident's room. Resident 16 was observed looking at the decorations for one minute, then exiting the room. No other residents were in the room. At 11:50 AM resident 16 was then observed walking around the nurses' station, and then entered 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 · D2022-08-18 · tag F0675 — failed to support quality of life — isolatedHonor each resident's preferences, choices, values and beliefs.
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 medical record review, it was determined, for 2 of 18 sample residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. Specifically, residents that wandered and took other resident's posessions were not prevented from wandering into other residents' rooms, resulting in those residents' psychological distress. Resident identifiers: 27 and 29. Findings include: 1. Resident 27 was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, epilepsy, depression, and heart failure. On 8/16/22 at 10:00 AM, resident 27 was interviewed. Resident 27 stated that other residents wandered into his room. Resident 27 stated that he kept his door closed and had a stop sign, but it didn't do any good. On 8/18/22, resident 27's medical record review was completed.…
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 before2022-08-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 18 sample residents, that the facility did not ensure that the residents' environment remained as free of accident hazards as possible; and that the residents received adequate supervision and assistance devices to prevent accidents. Specifically, residents were wandering throughout the facility and into other residents' rooms that could pose accident hazards. Wandering residents entered residents' rooms who had threatened them, and supervision was not provided to avoid tripping hazards. Resident identifiers: 9, 16 and 33. Findings include: 1. Resident 9 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, glaucoma, anxiety disorder, dysphagia, and insomnia. On 8/18/22, resident 9's medical record review was completed. On 6/1/22, resident 9 received a Minimum Data Set (MDS) quarterly assessment. Resident 9's cognitive status was evaluated at 4/15, meaning severe cognitive impairment. Nursing notes…
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
$11,193 in federal fines across 1 penalty.
- $11,193 — penalty dated 2025-05-05
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 |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in UT
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. 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 46A070. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-05, 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.