The Terrace Transitional
400 East 5350 South, Ogden, UT 84405 · For profit - Corporation · 120 certified beds · (801) 479-9855 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 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.
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 | 10.2% | 11.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 3.3% | 3.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.9% | 0.7% | 0.9% | typical |
| Long-stay residents with a urinary tract infection | 1.6% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 47.3% | 16.5% | 6.5% | worse 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 | 1.6% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 17.0% | 15.1% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 38.2% | 25.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.8% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.2% | 3.9% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 17.4% | 21.5% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.3% | 14.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 0.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 88.9% | 91.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 10.6% | 16.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.6% | 11.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.91 | 1.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 0.55 | 1.43 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
48.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 42 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.3% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 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 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 48.1%CMS range 32.3–60.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 6.4–14.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 63.3% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 60.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 36.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 94.4% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.5%CMS range 3.9–13.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.96 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 120 beds and averages 92.8 residents a day — about 77% occupied, or roughly 27 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.34 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.90 hrs/resident/day on weekends vs 3.52 on weekdays — 18% thinner on weekends. RN hours go from 0.91 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 44% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · D2024-10-08 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined there was a delay in care for a resident complaining of leg numbness and weakness for 1 of 4 sampled residents. Resident identifier: 1. Findings Include: Resident 1 was admitted to the facility on [DATE] and discharged on 6/30/2024 with diagnoses of wedge compression fracture of the thoracic (t) vertebra of t7-t8 , multiple rib fractures, muscle weakness, cognitive communication deficit, and schizophrenia. On 6/26/2024 at 12:38 PM, a provider documented a cranial nerve exam and neurological exam was conducted on resident 1 due to complaints of being unable to move or feel their legs for the last day. The provider documented no abnormalities were noted. Resident 1 had been able to feel and move their lower extremities at the time of the exam. On 6/29/2024 at 4:48 AM and 11:54 AM, licensed practical nurses documented resident 1 had complained of lower extremity paralysis. There was no provider documentation or communication located to indicate the provider…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-29 · tag F0607 — failed to have anti-abuse policies — patternDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility did not develop and implement written policies and procedures that; prohibit and prevent abuse, neglect, and exploitation of residents. Specifically, for 2 out of 5 sampled staff members, the facility did not follow their abuse policy by screening prospective employees licenses prior to employee working with residents. Findings included: A review of employee records revealed the following: Employee 1 was a Nursing Assistant (NA) hired by the facility on 7/31/23, and started working on the floor on 8/10/23. There was no record of Employee 1's license being checked to verify that a previous license had not been obtained. Employee 2 was a Certified Nursing Assistant (CNA) was hired by the facility on 2/2/23, and started working on the floor on 3/6/23. Employee 2's license was verified on 7/28/23. A review of the facility's abuse policy and procedures revealed the following: . a. Screening: Prospective Employees 1. Prior to hire, the Facility will screen potential employees for a history of abuse, neglect, exploitation, or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-29 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review it was determined, for 12 of 36 sampled residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, there were observations of resident's call lights alarming up to 30 minutes before assistance was provided, residents complained of long call light wait time and resident council minutes revealed resident concerns with staffing. Resident identifiers: 10, 12, 14, 20, 29, 34, 38, 56, 58, 70, 133 and 383. Findings include: 1. Observations of Call lights: a. On 8/25/24 at 8:26 AM, an observation was made of a call light on in 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.
- Potential for harm · E2024-08-29 · tag F0770 — failed to provide lab services — patternProvide 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 2. Resident 22 was admitted to the facility on [DATE] with diagnoses which included spastic hemiplegia affecting right dominate side, intracranial injury without loss of consciousness, muscle weakness, hypothyroidism, hypertension, pressure hydrocephalus, epilepsy, schizophrenia, and major depressive disorder. Resident 22's medical record was reviewed on 8/25/24 through 8/28/24. On 10/23/23, resident 22's TSH level was 0.079 which was low. It was written on the laboratory results Reduce Levothyroxine to 125 mcg [micrograms] recheck in 6 weeks. Signed with a date of 10/26/23. A physician's order dated 10/26/23, revealed TSH one time a day for lab. On 12/7/23, there was a laboratory results that revealed Test not performed. Insufficient specimen to perform or complete. A physician's order dated 2/4/24, revealed CBC and CMP urgently for lethargy. On 2/5/24, there was a laboratory results form that revealed Test not performed. The required specimen for the test ordered was not received . Comp. [comprehensive]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-29 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review it was determined, for 10 of 36 sampled residents, that the facility did not provide food prepared by methods that conserve flavor and appearance or provide food and drink that was palatable, attractive, and at an appetizing temperature. Specifically, there were multiple complaints from residents about the quality of the food, there were multiple resident council complaints about the flavor of the food, and a test tray was bland to the taste with overcooked foods. Resident identifiers: 10, 12, 14, 20, 28, 34, 38, 56, 59, and 68. Findings Include: On 8/25/24 at 12:51 PM, an interview was conducted with resident 10. Resident 10 stated that the food served at the facility was not good. Resident 10 stated that the food served gave her diarrhea. Resident 10 stated that the eggs and oatmeal served were not good and caused her to have constipation. At 2:02 PM, an additional interview was conducted with Resident 10. Resident 10 stated that the food served was so bad that she had called her son to bring her food from fast food for lunch. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-08-29 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 1 out of 36 sampled residents, a medication was touched by bare hands and administered to a resident and hallway meal trays were not delivered in a sanitary manner. Resident identifier: 28. Findings Included: 1. On 8/27/24 at 7:44 AM, an observation was made of Registered Nurse (RN) 4 during medication pass. RN 4 removed a pill that was taped back into a bubble pack. RN 4 was unable to remove the pill from the tape and pulled the pill off the tape and dropped the pill into the medication cup. RN 4 administered the pill to resident 28. On 8/27/24 at 7:50 AM, an interview was conducted with RN 4. RN 4 stated that she would not tape medications back into the bubble pack. RN 4 stated she would discard the medication and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-29 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
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 for 1 out of 36 sampled residents, the facility did not treat each resident with respect and dignity and care for each resident in a manner in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, a resident was covered in towels in a shower chair with the sides of her buttocks exposed and being pulled backwards through the hallway. Resident Identifier: 56. Findings included: Resident 56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, chronic obstructive pulmonary disease, bipolar disorder, major depressive disorder, adjustment disorder with anxiety, cognitive communication deficit, and muscle weakness. On 8/26/24 at 11:16 AM, an observation was made of resident 56 being pulled backwards in a shower chair by Certified…
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 · D2024-08-29 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 the facility did not provide, 4 of 36 sampled residents, the right to have secured and confidential personal and medical records. Specifically, the computer screen was left open on the medication carts with resident personal information and a nurse report paper was left face up on the medication cart with resident personal information. Resident identifiers: 4, 8, 70, and 76. Findings included: On 8/25/24 at 1:46 PM, an observation was made of Licensed Practical Nurse (LPN) 2. LPN 2 was observed to leave the computer screen open on the medication cart in the 200 hallway and walked away from the computer down the hallway. Residents 8, 70, and 76 were observed to be near the medication cart. On 8/26/24 at 7:23 AM, an observation was made of Registered Nurse (RN) 5. RN 5 was observed to leave the computer screen open on the medication cart in the 200 hallway and walked into resident room [ROOM NUMBER]. Resident 4 was observed to be walking by the medication cart. On 8/27/24 at 7:30…
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 · D2024-08-29 · tag F0622 — isolatedNot 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, the facility did not ensure that the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider. Specifically, for 1 out of 36 sampled residents, a resident did not have any transfer documentation in their medical record when they were transferred to the hospital. Resident identifier: 8. Findings included: Resident 8 was admitted to the facility on [DATE] with diagnoses that include, but were not limited to, hereditary and idiopathic neuropathy, asthma, cognitive communication deficit, weakness, reduced mobility, borderline personality disorder, major depressive disorder, anxiety disorder, chronic obstructive pulmonary disease, malingerer, and panic disorder. Resident 8's medical record was reviewed from 8/25/24 to 8/29/24. Resident 8's progress notes revealed the following: a. On 7/26/24 at 12:12 AM, a nursing note documented, Resident's roommate came out into 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 · D2024-08-29 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 provide written information to the resident or resident representative that specifies the duration of the state bed-hold policy, if any, during which the resident was permitted to return and resume residence in the nursing facility. Specifically, for 2 out of 36 sampled residents, resident's were transported to the hospital and were not informed of the facility bed-hold policy. Resident identifiers: 8 and 56. Findings included: 1. Resident 56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, bipolar disease, and anemia. Resident 56's medical record was reviewed on 8/25/24 through 8/29/24. Resident 56's progress notes revealed on 4/5/24 at 6:20 PM, Called to residents' room by her mother stating her daughter doesn't seem right, I entered…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · Dcited before2024-08-29 · 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 interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents. Specifically, for 2 out of 36 sampled residents, a resident that was considered an elopement risk with a wandergaurd left the facility unattended and the resident was a smoker without a smoking assessment. In addition, another resident that had an unwitnessed fall and did not have neurological checks completed. Resident identifiers: 59 and 185. Findings included: 1. Resident 185 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, acute on chronic systolic congestive heart failure, moderate protein-calorie malnutrition, chronic obstructive pulmonary disease, mild intellectual disabilities, cognitive communication deficit, urinary tract infection, dementia, alcohol abuse, and essential hypertension. Resident 185's medical record was reviewed on 8/25/24. On 7/8/23 at 6:22 PM, the Elopement/Wandering Evaluation documented that resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-29 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 provide pharmaceutical services which included procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. Specifically, for 1 out of 36 sampled residents, the resident did not have gabapentin available. Resident identifier: 14. Findings included: Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute on chronic combined systolic and diastolic heart failure, type 2 diabetes mellitus, morbid obesity, reduced mobility, and muscle weakness. On 8/25/24 at 11:36 AM, an interview was conducted with resident 14. Resident 14 stated she had a sciatica problem and it flared up in the morning. Resident 14 stated she had requested to see the physician regarding changing times of her muscle relaxer. Resident 14 stated her pain was 10 out of 10 every morning and the pain woke her up at night. Resident 14's medical record…
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 · D2024-08-29 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 of 36 sampled resident, 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 indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, blood pressure medication was administered when a residents blood pressure was outside of the physician ordered parameters. In addition, another resident missed his antipsychotic and diuretic medication because he was scheduled for dialysis during the scheduled administration time. The same resident was not administered insulin according to physician's orders. Resident identifiers: 22 and 34. Findings included: 1. Resident 22 was admitted to the facility on [DATE] with diagnoses which included spastic hemiplegia…
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 · D2024-08-29 · 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, the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, an opened multi-dose vial in the medication cart had exceeded the 28 day expiration date, an insulin pen was not dated with the date it was opened, and bubble packs had medication taped back in. Resident identifiers: 28. Findings included: 1. On 8/27/24 at 7:00 AM, the medication cart at the top of the 100 hallway was inspected. An observation was made that the medication cart contained a Lispro insulin vial with an open date of 7/21/24, and a used glargine insulin pen with no open or expiration date on it. An interview was conducted with Registered Nurse (RN) 3. RN 3 stated that opened insulin was good for 28 days and then it must be discarded. RN 3 stated she was unsure when the insulin pen was opened and the vial of insulin needed to be removed from the cart. 2. On 8/27/24 at 7:44 AM, an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-08-29 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement a program that monitors antibiotic use.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, for 1 out of 36 sampled resident, staff were not aware of who and why a resident was ordered prophylaxis antibiotics. Resident identifier: 56. Findings included: Resident 56 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, type 2 diabetes mellitus, chronic obstructive pulmonary disease, bipolar disorder, major depressive disorder, and anxiety. Resident 56's medical record was reviewed on 8/25/24 through 8/29/24. A care plan dated 3/3/24, revealed Is on Antibiotic Therapy r/t [related to] UTI. The goal was Will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. The interventions included Administer medication as ordered and Observe for possible side effects every shift. On 6/2/24 at 1:48 PM, a Nurse Practitioner / Physician'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.
- Potential for harm · E2024-08-29 · tag F0802 — failed to prepare enough nourishing food — patternProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility did not provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Specifically, surveyors made multiple observations of the lunch and meal services being served and delivered later than the posted meal times, there were multiple resident complaints about food being served late and cold, and there were multiple recent resident council notes documenting resident complaints about food being served cold and late. Resident Identifiers: 12 and 28. Findings Include: The following meal times were provided upon entrance: Breakfast 7:30 AM Residents to dining hall by 7:15 AM Food comes out by 7:30 AM Hall 100 trays served at 8:00 AM Hall 200 trays served at 8:30 AM Hall 100 trays back to kitchen by 9:00 AM Hall 200 trays back to kitchen by 9:30 AM Lunch 11:30 AM Residents to dining hall by 11:15 AM Food comes out by 11:30 AM Hall 100 trays served at 12:00 PM Hall 200 trays served at 12:30 PM Hall 100 trays back to kitchen by 1:00 PM Hall 200…
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 · E2022-12-15 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
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, for 5 of 27 sampled residents, that the facility did not provide a safe, clean comfortable and homelike environment. Specifically, resident wheelchairs were dirty and a lift was dirty. Resident identifiers: 13, 17, 33, 34, and 52. Findings include: 1. On 12/13/22 at 1:45 PM, resident 33 was observed in her wheelchair. Resident 33 wheelchair was observed to have a soiled wheelchair cushion, the sides and wheels of her wheelchair were soiled. On 12/15/22 at 12:46 PM, an observation was made of resident 33's wheelchair. Resident 33's wheelchair was observed to have a soiled cushion. In addition, the sides and wheels of her wheelchair were soiled. 2. On 12/15/22 at 12:26 PM, an observation was made of resident 52's wheelchair. Resident 52's wheelchair was observed to have a green pad on it. There was food and debris on the pad. There was a strong urine odor. There was debris on the sides of the cushion and the wheels were soiled. 3. On 12/15/22 at 12:55 PM, an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-12-15 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review it was determined, for 12 of 27 sampled residents, that the facility did not serve food that was prepared by methods that conserved nutritive value, flavor, and appearance or serve food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained of cold and unappetizing food. In addition, green beans and peas were overcooked and resident council minutes revealed residents' complaints of food quality. Resident identifiers: 1, 7, 13, 20, 34, 37, 41, 45, 49, 55, 59, and 61. Findings Included: 1. On 12/13/22 at 2:56 PM, resident 1 was interviewed. Resident 1 stated that the eggs were usually cold and not good. 2. On 12/13/22 at 3:01 PM, resident 7 was interviewed. Resident 7 stated that the food was always cold by the time they received it. 3. On 12/13/22 at 1:35 PM, resident 13 was interviewed. Resident 13 stated that the food was cold. 4. On 12/13/22 at 1:08 PM, resident 20 was interviewed. Resident 20 stated that the food was the worst part of the facility. The food was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-12-15 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, uncooked meats were stored above ready to eat foods, there were soiled areas in the kitchen, cracked paint, missing grout and broken tiles. Findings Include: 1. On 12/13/2022 at 9:46 AM, an initial tour of the kitchen was conducted. The following was observed: a. In the walk-in refrigerator, a box of raw hamburger patties was found stored above breadsticks. b. Inside the walk-in freezer there were large chunks of ice on the floor and ice circles hanging from the ceiling. c. The door handle from the kitchen to the dining room was observed to have crumbs and debris in it. d. There was cracked paint and drywall under the vents above the stove. e. Underneath the prep sink a tile was missing. f. There was missing grout on the tile in front of the oven. g. Crumbs and debris were found around the edges of the flooring. 2. On 12/15/2022 at 1:37 PM, a follow up tour of the kitchen was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-15 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 1 of 27 sampled residents, that based on the comprehensive assessment residents were not provided the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish. Specifically, a resident was not provided oral care and was observed with build up on her teeth. Resident identifier: 33. Findings include: Resident 33 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, anxiety, mood disorder, major depressive disorder, contractures to right shoulder, left hip and right hip, left hand contracture, left shoulder, left elbow, left wrist, right knee, left ankle, and right hand. On 12/13/22 at 1:45 PM, an observation of resident 33 was made. Resident 33 was observed to have white and yellow build up substance on her teeth around the gum line. Resident 33's medical record was reviewed on 12/15/22. 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 · D2022-12-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
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 27 sample residents, that the facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, a resident did not receive brief changes, skin checks, and toileting services in coordination with good nursing care and outlined in the resident's care plan. Resident identifier: 24. Findings include: Resident 24 was admitted to the facility on [DATE] with diagnoses that included rheumatoid arthritis (RA), hemiplegia, cerebral infarction, left hand, shoulder and elbow contractures, osteoarthritis, depression, bilateral knee contractures, depression, and cognitive communication deficit. Resident 30's medical record review was completed on 12/15/22. On 12/13/22 at 12:30 PM, resident 24 was observed in the activity room. Resident 24 was able to answer in yes and no answers to a few questions. On 12/14/22 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 · D2022-12-15 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
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 27 residents that the facility failed to reevaluate the risks versus benefits of the installed side rails for a resident. Specifically, one resident had a skin tear occur from the use of the current side rail. Resident identifier: 3. Findings Include: Resident 3 was admitted to the facility on [DATE] with diagnoses which included heart failure, type 2 diabetes mellitus, morbid obesity, and reduced mobility. On 12/13/22 at 12:01 PM, an interview was conducted with resident 3. Resident 3 stated she injured her left forearm on the inside of the side rail. Resident 3 stated that the inside of her side rail had something that stuck out for her to put her remote in. Resident 3 stated that her arm slid off the side of the rail and scraped the part for the remote-control holder. Resident 3 stated this happened on a day she wasn't coordinated and couldn't control her upper body. Resident 3's medical records were reviewed on 12/14/22 A Minimum Data Set (MDS)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2021-05-06 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, recently-washed dishes were observed to be placed with clean dishes when the dishmachine did not reach the manufacture required temperatures for sanitation. In addition, there was no process to track when health shakes were removed from the freezer and placed in the refrigerator. Findings include: 1. On 5/6/21 at 1:14 PM, an observation was made of the facility dishmachine. Dietary Aide (DA) 1 was observed to be scraping dishes, loading the dishmachine and putting dishes away. The following temperatures was observed: [Note: All temperatures were in degrees Fahrenheit.] a. At 1:14 PM, the washing cycle was 100 and the rinse cycle was 110. DA 1 stated it usually takes a few times running it to get to temp (temperature). b. At 1:22 PM, the washing cycle was 110 and the rinse cycle was 120. There were 2 dish machine baskets removed from the dishmachine. In the baskets was 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 · Ecited before2021-05-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined for 5 of 22 sample residents, that the facility did not ensure the resident's environment remained as free from accident hazards as possible and that each resident received adequate supervision and assistance to prevent accidents. Specifically, residents were observed to not be using smoking equipment and a resident sustained feet injuries while operating an electric wheelchair without a follow-up assessment or intervention. In addition, a resident did not have items available to prevent falls. Resident identifiers: 22, 34, 35, 50 and 58. Findings include: 1. On 5/3/21 at 11:00 AM, three smoking aprons were observed hanging on the south wall next to the east exit, where the residents exited the building to the smoking area. An observation was made of resident's smoking outside under a tent. There were no residents observed to have a smoking apron or other smoking equipment. There was one staff member with the residents. a. Resident 22 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-06 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each 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 observation, interview, and record review it was determined, for 2 of 22 sample residents, that the facility did not assist residents in obtaining routine and 24-hour emergency dental services and did not promptly, within 3 days, refer residents with lost or damaged dentures for dental services. Specifically, the facility did not follow-up when a resident's dentures did not fit properly and were painful to wear and another resident had painful teeth with bleeding gums. Resident identifiers: 1 and 49. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, functional quadriplegia, anxiety disorder, major depressive disorder, cognitive communication deficit, and protein-calorie malnutrition. On 5/3/21 at 9:29 AM, resident 1 was observed without her dentures in her mouth. Resident 1 was interviewed and stated that her dentures were too big and she could not get a dental appointment. On 5/6/21 at 8:58 AM, an interview was conducted with…
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 · D2021-05-06 · tag F0801 — isolatedEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview and record review it was determined that the facility did not employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility did not a employee a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. Findings include: On 5/6/21 at 12:27 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that she would complete her Certified Dietary Manger course in October, 2021. The DM stated that the Registered Dietitian (RD) was in the building every Thursday. The DM stated that the RD was available by phone anytime.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.2 | -0.2 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 4 of 5 | 2.7 | +1.3 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| DELAHUNTY, COLIN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2019 |
| STELTER, CASEY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2019 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | since 08/01/2019 |
| KEETCH, CHAD | Individual | CORPORATE OFFICER | since 03/01/2011 |
| MOSS, TYLER | Individual | CORPORATE OFFICER | since 08/01/2019 |
| WATERFALL CANYON HEALTHCARE, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2019 |
| BURCH CREEK HEALTH HOLDINGS LLC | Organization | ADP OF THE SNF | since 08/01/2019 |
| ENSIGN SERVICES INC | Organization | ADP OF THE SNF | since 05/14/2019 |
| STANDARD BEARER HEALTHCARE OP, LP | Organization | ADP OF THE SNF | since 08/01/2019 |
| THE ENSIGN GROUP INC | Organization | ADP OF THE SNF | since 08/01/2019 |
CMS files one row per role, so the 15 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 78% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.0M paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in UT
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Utah Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 465115. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-29, 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 →
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