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Maple Springs Senior Living

350 East 2200 North, North Logan, UT 84341 · For profit - Corporation · 98 certified beds · (435) 753-9400 Medicare only — no Medicaid

Call the home — (435) 753-9400 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Nov 2023Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$8,278 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • 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 (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $8,278 in federal fines (most recent 2025-12-08)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Pharmacy
2245 N 400 E · (435) 787-1212 · Call to confirm hours
Grocery
475 E 2500 N · (435) 554-8191 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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 5 of 5
Short-stay residentsrehab / post-hospital 2 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 2 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.4%11.3%15.4%better
Long-stay residents who lose too much weight6.8%3.4%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection1.6%1.8%2.0%better
Long-stay residents with depressive symptoms5.7%16.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.0%2.5%3.3%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication20.5%25.3%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers3.0%3.9%4.7%better
Long-stay residents with worsening bladder/bowel control33.8%21.5%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table33.3%14.2%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.6%0.9%1.4%worse
Short-stay residents given the seasonal flu vaccine90.3%91.0%79.4%better
Short-stay residents rehospitalized after admission25.5%16.5%22.6%worse
Short-stay residents with an outpatient ER visit12.1%11.6%12.0%typical

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

65.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 242 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

65.5%U.S. median 51.5%
Got home and stayed home
9.1%U.S. median 10.7%
Went back to hospital
34.5%U.S. median 56.6%
Met the expected recovery
0.80U.S. median 0.31
Therapy hours / resident / day
0.37hours / resident / day
Physical therapy
0.36hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 34.5% 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 113 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 0.80 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF65.5%CMS range 60.8–69.751.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.1%CMS range 6.5–12.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge34.5%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge25.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge59.3%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.0%CMS range 3.5–9.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.041.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.49
RN hours/ resident / day
0.77
LPN hours/ resident / day
3.62
Aide hours/ resident / day
5.88
Total nurse hours/ resident / day
0.98
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 98 beds and averages 37.0 residents a day — about 38% occupied, or roughly 61 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.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.88 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.49 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.62 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 5.50 hrs/resident/day on weekends vs 6.04 on weekdays — 9% thinner on weekends. RN hours go from 1.70 to 0.98 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

5
deficiencies at the latest standard inspection (2026-02-25)
12
at the previous standard inspection (2023-11-16)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

22 citations, most serious first. The 11 most serious are shown; the remaining 11 are one tap away and print in full.

  • Actual harm · G2025-12-08 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined for 1 of 5 sampled residents, that the facility failed to provide each resident with a safe diet that met the special dietary needs of each resident. Specifically, a resident had a diet order for moist and minced texture and was given a cheese stick and pretzels for a snack which resulted in the resident choking and passing away. Resident identifier: 1It was determined the provider's noncompliance with this rule caused harm. However, based on the facility's corrective actions and a review of its current compliance, the deficiency was determined to be past noncompliance. The facility developed and implemented a corrective action plan before the survey start date. The facility's corrective action plan, which was developed and implemented by December 3, 2025, included the following measures. The Director of Nursing (DON) added a column on the Nurse report sheet to identify textures and diets for all current residents. The DON audited diets and textures to…

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

    Nutrition and Dietary Deficiencies · Past Non-Compliance
  • Potential for harm · Fcited before2026-02-25 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, food items in the refrigerator and freezer were undated, and sanitizer buckets did not meet the required sanitation testing levels. Findings included: 1. On 2/23/26 at 8:25 AM, an initial tour of the kitchen was conducted. The following observations were made: a. The Dietary Manager (DM) was behind the preparation table and was not wearing a hairnet. b. An opened and undated bag of whipped topping was in the refrigerator. c. A pan of meatballs was undated in the refrigerator. d. A bag of frozen rolls were opened and undated in the freezer. e. The sanitation bucket at the preparation table was tested by the DM and resulted at 150 parts per million (PPM). The DM stated that the level should be at 200 PPM. The DM stated that she needed to pour out the water from the bucket and start again. The DM stated that the sani buckets were changed at least three times a day after every meal service. 2. On 2/24/26 at…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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, for 1 of 39 sampled residents, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice. Specifically, a resident was not provided crushed medications as ordered by the physician. Resident identifier: 64. Findings include: Resident 64 was admitted to the facility on [DATE] and discharged on 1/5/26 with diagnoses which included fractures of right pubis and left pubis, sacrum fracture, dysphagia, and age-related osteoporosis. Resident 64's medical record was reviewed 2/23/26 through 2/25/26. The facility reported to the SSA on 12/30/25, that resident 64's family reported resident 64 was receiving whole pills instead of crushed medications. The investigation revealed that resident 64 had 3 medications that were not able to be crushed. Resident 64's Discharge Summary from the hospital dated 12/20/25, revealed resident 64 was observed to have an episode of choking on toast while eating breakfast. There 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure each resident had supervision to prevent accidents. Specifically, for 2 out of 39 sampled residents, a resident was not secured in the facility van and tipped backwards sustaining a closed head injury. This example was cited at a harm level. Resident identifier: 73. Findings included: Resident 73 was admitted to the facility on [DATE] and discharged on 6/21/25 with diagnoses which included urinary tract infection, acute respiratory failure with hypoxia, chronic kidney disease, hypertension, diastolic heart failure, and anxiety. The facility reported to the State Survey Agency (SSA) on 5/29/25, that resident 73 was transported to an appointment when her wheelchair tipped backwards and she bumped her head on the ramp that was folded up behind her. The transport driver asked resident 73 if she was okay, tipped the wheelchair upright, and strapped the front of the chair in, and took her to instacare where her appointment was and ensured that 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, 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, for 1 out of 39 sampled residents, a controlled drug was stored in a manner that failed to prevent potential drug diversion and ensure safe medication administration. Resident Identifier: 21. Findings included: On 2/25/26 at 10:38 AM, during a review of the facility's medication carts, an observation was made of a blister pack containing Percocet 10-325 milligram tablets. The blister pack had 1 tablet taped into an opened blister cell. The Percocet, a Schedule II narcotic, was prescribed for resident 21. At the time of the observation an interview was conducted with Registered Nurse (RN) 2. RN 2 stated medication tablets should not be taped back into blister cells to prevent the incorrect medication from being replaced in the blister cell. Additionally, RN 2 stated if a narcotic tablet was removed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-25 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, 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 disease and infections. Specifically, for 2 out of 39 sampled residents, one resident had a urinary catheter bag observed on the floor, and for a second resident receiving wound care, hand hygiene and glove changes were not performed. Resident identifiers: 2 and 9. Findings included: 1. Resident 9 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction, retention of urine, and obstructive and reflexive uropathy.Resident 9's medical record was reviewed.A physician's order with a start date of 1/28/26, documented, Catheter cares: Clean foley site with soap and water, check foley for kinks and that foley bag is being kept below the bladder and off the floor in privacy bag. every morning 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-16 · tag F0622 — pattern
    Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 3 of 23 sampled residents, that the facility did not ensure that when the facility transferred or discharged a resident that the information provided to the receiving provided included: contact information of the practitioner responsible for the care of the resident; resident representative information including contact information; Advanced Directive information; all special instructions or precautions for ongoing care; all other necessary information, including a copy of the resident's discharge summary; and any other documentation to ensure a safe and effective transition of care. Specifically, residents were transferred to the hospital and no documentation could be found of the information that was provided to the receiving provider. Resident identifier 32, 39 and 93. Findings included: 1. Resident 39 was admitted to the facility on [DATE] with diagnosis of fracture of lower end of left humerus. On 11/15/23, resident 39's medical records 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-11-16 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food in the refrigerator was not dated and labeled. In addition, there were soiled areas in the kitchen. Findings included: 1. On 11/13/23 at 11:07 AM, an initial tour of the kitchen was conducted. The following observations were made: a. The floor in the bistro area under the cappuccino machine had black build up and debris in the corners. b. The doors and handles on the refrigerator in the bistro area were soiled. c. There was a container labeled Cream Cheese Frosting with no open date or expiration date in the walk in refrigerator. d. There was thawed Whipped Topping in the walk in refrigerator with no date when it was pulled from the freezer. The label revealed to use thawed Whipped Topping within 2 weeks. e. There was black substance in the corners of the kitchen, around table legs and under shelves throughout 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not consult with the resident's physician; and notify when there was a significant change in the resident's physical, mental, or psychosocial status. Specifically, a resident expressed feelings of suicidal ideation and the physician was not notified. Resident identifier 39. Findings included: Resident 39 was admitted to the facility on [DATE] with diagnosis of fracture of lower end of left humerus. On 11/15/23, resident 39's medical records were reviewed. On 9/7/23, resident 39's Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 00/15, which would indicate that the resident had a severe cognitive impairment. Review of resident 39's physician orders revealed the following: a. Seroquel Oral Tablet 25 milligram (mg) (Quetiapine Fumarate), give 12.5 mg by mouth every morning and at bedtime for Anxiety/Delusions. The order was initiated and discontinued 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 23 sampled residents, that the facility did not ensure that all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the the allegation was made to the administrator, State Survey Agency (SSA), and Adult Protective Services. Specifically, a resident eloped from the facility and the State Survey Agency was not notified. Resident identifier 39. Findings included: Resident 39 was admitted to the facility on [DATE] with diagnosis of fracture of lower end of left humerus. On 11/15/23, resident 39's medical records were reviewed. On 9/7/23, resident 39's Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 00/15, which would indicate that the resident had a severe cognitive impairment. The assessment documented that resident 39 was a one-person limited assist for ambulation. On 9/10/2023 at 6:08 PM, the resident 39's progress note documented, Pt's…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 1 of 23 sampled residents, that the facility did not ensure that the resident received care, consistent with professional standards of practice, to prevent the development of pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, a resident developed a new pressure ulcer after admission to the facility and interventions were not implemented specific to the prevention of its development. Resident identifier: 23. Findings included: Resident 23 was admitted to the facility on [DATE] with diagnoses which included displaced fracture of left humerus, syncope and collapse, chronic kidney disease, dementia, peripheral vascular disease, prediabetes, history of venous thrombosis, and long term use of anticoagulants. On 11/14/23 at 9:43 AM, an observation was made of resident 23. Resident 23 right lower extremity was positioned in a podus boot with a stocking over the top of the foot.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · Dcited before2023-11-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 out of 23 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards was was possible and that the resident received adequate supervision to prevent accidents. Specifically, a resident who was identified as exit seeking did not have adequate supervision to prevent the resident from eloping. Resident identifier: 39. Findings included: Resident 39 was admitted to the facility on [DATE] with diagnosis of fracture of lower end of left humerus. On 11/15/23, resident 39's medical records were reviewed. On 9/7/23, resident 39's Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 00/15, which would indicate that the resident had a severe cognitive impairment. The assessment documented that resident 39 was a one-person limited assist for ambulation. Review of resident 39's physician orders revealed the following: a. Seroquel Oral Tablet 25 milligram (mg)…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 23 sampled residents, that 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; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, a resident's medication was not administered per the physician ordered parameters. Resident identifier: 26. Findings included: Resident 26 was admitted to the facility on [DATE] with diagnoses which included acute posthemorrhagic anemia, dissection of thoracoabdominal aorta, atrial fibrillation, heart failure, depression, diabetes and fibromyalgia. Resident 26's medical record was reviewed 11/13/23 through 11/16/23. A form from a home health company dated 10/27/23 revealed an order for ergocalciferol 1.25 milligrams (mg) (500 intl (international) units) oral capsule (cap). Administration of 1 cap every week.…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 out of 23 sampled residents, that the facility did not ensure that residents who have not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, a resident was prescribed an antipsychotic medication for insomnia. Resident identifier: 31. Findings included: Resident 31 was admitted on [DATE] with diagnoses which included laceration of muscles and tendons of the right lower extremity, tear of meniscus, coronary artery disease, chondromalacia, gout, dysarthria and anarthria, polyneuropathy, tremor, polyosteoarthritis, thrombocytopenia, hypothyroidism, and presence of bypass graft. On 11/15/23, resident 31's medical records were reviewed. Resident 31's physician orders revealed an order for Seroquel Oral Tablet 50 milligrams (mg) (Quetiapine Fumarate), give 1 tablet by mouth at bedtime for agitation. The order was initiated 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined, that the facility did not provide or obtain laboratory services to meet the needs of its residents. Specifically, for 2 of 23 sampled residents, a urinalysis was not done as requested by the provider and a resident did not have ordered labs completed. Resident identifiers: 31 and 32. Findings included: 1. Resident 32 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, unspecified fracture of fifth lumbar vertebra, type 2 diabetes mellitus, paroxysmal atrial fibrillation, infection, and inflammatory reaction due to indwelling urethral catheter, severe sepsis, and personal history of urinary tract infections. Resident 32's medical record was reviewed on 11/14/23. On 9/16/23 at 5:21 PM, a nurse note stated, Pt [patient] continues on PO [by mouth] ABTx [antibiotics] for UTI [urinary tract infection], however, urine remains significantly bloody. Received orders from [name removed] to do a f/u [follow up] UA [urinalysis] 72…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0775 — isolated
    Keep complete, dated laboratory records in the resident's record.
    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 23 sample residents, that the facility did not ensure that resident's laboratory reports were filed in the clinical record. Specifically, a resident's urine culture results were not in the resident's medical record. Resident identifier 32. Findings Included: Resident 32 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, unspecified fracture of fifth lumbar vertebra, type 2 diabetes mellitus, paroxysmal atrial fibrillation, infection, and inflammatory reaction due to indwelling urethral catheter, severe sepsis, and personal history of urinary tract infections. Resident 32's medical record was reviewed on 11/14/23. A physician order dated 9/8/23 for a urinalysis and culture and sensitivity due to signs and symptoms of a UTI was reviewed. The laboratory results for the above listed physician's order were not located in resident 32's electronic medical record. Resident 32 progress notes were reviewed 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-16 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 23 sampled residents, that in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that was complete; accurately documented; readily accessible; and systematically organized. Specifically, a resident's physician's orders did not match the medication administered. Resident identifier: 26. Findings included: Resident 26 was admitted to the facility on [DATE] with diagnoses which included acute posthemorrhagic anemia, dissection of thoracoabdominal aorta, atrial fibrillation, heart failure, depression, diabetes mellitus and fibromyalgia. Resident 26's medical record was reviewed 11/13/23 through 11/16/23. Resident 26's admission physician's orders dated 10/27/23 revealed Metoprolol Succinate Extended Release (ER) 50 milligrams (mg) oral tablet daily (QD). A physician's order in resident 26's electronic medical record dated 10/27/23 revealed Metoprolol Tartrate 50 MG by mouth QD.…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-16 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined, the facility did not establish an infection prevention and control program that included, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, for 1 out of 23 sampled residents, a resident with a Urinary Tract Infection (UTI) was treated with the incorrect antibiotic that was not listed on the susceptibility laboratory report. Resident Identifier: 32 Findings Included: Resident 32 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, unspecified fracture of fifth lumbar vertebra, type 2 diabetes mellitus, paroxysmal atrial fibrillation, infection, and inflammatory reaction due to indwelling urethral catheter, severe sepsis, and personal history of urinary tract infections. Resident 32's medical record was reviewed on 11/14/23. Resident 32's progress notes were reviewed and documented the following: a. On 9/9/23 at 10:13 AM, a nurse note stated,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-01-13 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 3 of 23 sampled residents, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, an unvaccinated newly admitted resident on Transmission Based Precautions (TBP) did not isolate in their room for 14 days after admission and was allowed to exit the droplet isolation room to attend therapy services in the facility gym. Staff were observed not donning the appropriate Personal Protective Equipment (PPE) prior to entering rooms on droplet precautions, and did not sanitize their protective eyewear upon exit of droplet precaution rooms. Staff were observed to enter and exit a droplet precaution room without doffing the PPE prior to entering another resident room, and housekeeping equipment was taken into the droplet precaution room…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-01-13 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that medical records were complete, accurately documented, readily accessible and systematically organized for 3 of 23 sample residents. Specifically, hospice notes and physician visit notes had not been placed in the residents ' medical records. Resident identifiers: 17, 27 and 34. Findings include: 1. Resident 17 was admitted to the facility on [DATE] with diagnoses that included polyosteoarthritis, hereditary motor and sensory neuropathy, anxiety disorder, and atrial fibrillation. Resident 17's medical record was reviewed on 1/10/22. Review of resident 17 ' s medical record revealed that no physician visits notes had been placed in the resident ' s record since 7/16/21. On 1/13/22, the Director of Nursing (DON) provided physician visit notes indicating that resident 17 had been seen by the facility physician on 7/29/21, 8/5/21/21, 8/13/21, 8/20/21, 8/25/21, 9/8/21, 9/17/21, 10/2/21, 10/8/21, 10/14/21, 10/22/21, 10/26/21, 11/11/21, 11/19/21,…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-01-13 · tag F0886 — failed to test for COVID-19 as required — pattern
    Perform COVID19 testing on residents and staff.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined, for 5 out of 5 sampled staff, that the facility did not conduct testing based on parameters set forth by the Secretary. Specifically, routine testing of unvaccinated staff members, based on community transmission, was not completed two times per week. Staff identifiers: Staff 1, Staff 2, Staff 3, Staff 4, and Staff 5. Findings included: On 1/10/22 at 9:55 AM, an interview was conducted with the facility Administrator (ADM). The ADM stated that the facility receptionist kept the staff logs for testing and tracked who tested. The ADM stated that there were no scheduled days of the week for testing, and that staff could test any day. The ADM stated that it was difficult to ensure that all unvaccinated staff were testing two times per week according to the county community transmission rate. The ADM stated that staff were reluctant to come into the facility for testing if they were not already scheduled to work. On 1/11/22 the Centers for Disease Control and Prevention (CDC) COVID Data Tracker website listed the Level of Community…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-13 · tag F0712 — isolated
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    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 1 of 23 sample residents was seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. Specifically, a resident was not seen timely by a physician or physician surrigate. Resident identifier: 12, Findings included: Resident 12 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which consisted of Alzheimer's disease, dementia, osteoarthritis, irritable bowel syndrome, hypertension, major depressive disorder, gastro-esophageal reflux disease, hyperlipidemia, and obstructive and reflux uropathy. On 1/13/22 resident 12's medical records were reviewed. Review of resident 12's physician progress notes revealed physician visits occurred on 1/20/21, 3/19/21, 3/20/21, 3/30/21, 4/23/21, 6/1/21, 8/2/21, 10/4/21, and 1/6/22. It should be noted that 93 days lapsed from the visit on 10/4/21 to the visit on 1/6/22. On 1/13/22 at 11:48…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$8,278 in federal fines across 1 penalty.

  • $8,278 — penalty dated 2025-12-08

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.

Part of a chain

This home belongs to MAPLE SPRINGS LIVING — 3 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 53.0≈ chain avg
Health inspection 3 of 52.7+0.3 vs chain
Staffing 4 of 54.3-0.3 vs chain
Quality measures 4 of 53.3+0.7 vs chain
The other 2 homes this chain runs (chain average 3.0★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
BRONSHIELD LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST33%since 04/14/2017
MORPHEUS UNIVERSEOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST33%since 04/14/2017
PISTIS MERCURYOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF33%since 03/13/2026
DUNN, ELIZABETHIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/14/2017
DUNN, MARCIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 01/01/2016
LARSEN, GREGORYIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTORNO PERCENTAGE PROVIDEDsince 01/01/2016
LARSEN, NICHOLASIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 01/01/2016
PORTER, BRETTIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2025
TARBET, JESSICAIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2025
PATH ACCOUNTING LLCOrganizationADP OF THE SNFsince 04/14/2017

CMS files one row per role, so the 21 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$8.4M
Net patient revenuemost recent cost report
-5.9%
Operating marginrevenue minus expenses
$454K
Related-party expense5% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 13%Other / private 87%

This home reported $454K paid to related parties (affiliated landlords or management companies) in its most recent cost report. 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

$243per resident / day
operating cost
$7,382per month
≈ monthly operating cost
$229per day
avg. revenue, all payers

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

What families pay in UT

Paying with Medicaid

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

Typical monthly cost in Utah
$8,669/mo
Nursing home (semi-private)
$10,646/mo
Nursing home (private)
$5,475/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 465186. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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