No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Cascades at Orchard Park

740 North 300 East, Orem, UT 84057 · For profit - Limited Liability company · 52 certified beds · (801) 224-0921 Medicare & Medicaid certified

Call the home — (801) 224-0921 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0609, F0610) — most recent Mar 20251 actual-harm citation$11,992 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $11,992 in federal fines (most recent 2023-10-19)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (74%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 2 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
212 W 520 N · (801) 221-1220 · Call to confirm hours
Pharmacy
880 N State St · (801) 225-6002 · Call to confirm hours
Grocery
814 N 470 E
Park
600 N 300 E · (801) 229-7110 · Typically dawn to dusk
Place of worship
383 E 600 N

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
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 increased11.6%11.3%15.4%better
Long-stay residents who lose too much weight2.9%3.4%5.4%better
Long-stay residents with a catheter left in their bladder0.8%0.7%0.9%typical
Long-stay residents with a urinary tract infection1.6%1.8%2.0%better
Long-stay residents with depressive symptoms21.6%16.5%6.5%worse 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 injury1.5%2.5%3.3%better
Long-stay residents whose ability to walk worsened11.6%15.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication36.8%25.3%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers5.4%3.9%4.7%worse
Long-stay residents with worsening bladder/bowel control15.8%21.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table9.6%14.2%17.1%better
Short-stay residents who newly got an antipsychotic medication1.8%0.9%1.4%worse
Short-stay residents given the seasonal flu vaccine94.1%91.0%79.4%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.

9.8%U.S. median 10.7%
Went back to hospital
0.34U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.34 therapist hours per resident per day in 2026Q1 — more than 58% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 6.6–14.110.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified69.6%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 settingnot 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 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 stay8.7%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 worsened4.3%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.901.02Oct 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

1.18
RN hours/ resident / day
0.21
LPN hours/ resident / day
1.90
Aide hours/ resident / day
3.30
Total nurse hours/ resident / day
0.88
RN hoursweekends
73.8%
Total nursing turnover
45.5%
RN turnover

How full it usually is: this home is certified for 52 beds and averages 40.0 residents a day — about 77% occupied, or roughly 12 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 3.30 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 1.18 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.90 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 3.01 hrs/resident/day on weekends vs 3.41 on weekdays — 12% thinner on weekends. RN hours go from 1.30 to 0.88 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 74% is well above the national median of 45%. 1 administrator has left in the past year.

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

3
deficiencies at the latest standard inspection (2025-03-06)
8
at the previous standard inspection (2023-10-19)

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.

25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.

  • Actual harm · G2023-10-19 · 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, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 33 sampled residents, a resident that reported bruising, swelling, pain, and a fall did not receive an X-ray for three days after the fall that revealed fractures. This resulted in a finding of harm. Resident identifier: 139. Findings included: HARM Resident 139 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, spinal stenosis lumbar region, functional quadriplegia, radiculopathy lumbar region, moderate intellectual disabilities, major depressive disorder, congenital hydrocephalus, pain in thoracic spine, low back pain, and history of falling. Resident 139's medical record was reviewed on 10/17/23. A care plan Focus initiated on 8/14/21, documented [Resident 139] is at risk for falls…

    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 · Fcited before2025-03-06 · 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

    Based on interview, Centers for Disease Control (CDC) guidelines, and a review of Occupational Safety and Health Administration (OSHA) Respiratory Protection Guide, the facility failed to ensure all facility staff members had been fit tested for N95 respirators. This had the potential to affect 36 out of 36 residents residing in the facility. Findings included: The facility did not have a policy for fit testing N95 respirators. According to a United States Food and Drug Administration (FDA) publication, dated 10/21/2024, titled N95 Respirators, Surgical Masks, Face Masks, and Barrier Face Coverings, an N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles. A CDC publication, titled Infection Control Guidance: SARS-CoV-2 [severe acute respiratory syndrome coronavirus 2, a strain of coronavirus that causes COVID-19] dated 06/24/2024, indicated under the section Personal Protective Equipment, HCP [healthcare personnel] who enter the room of a patient with suspected or confirmed SARS-CoV-2…

    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 · D2025-03-06 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop 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 facility policy review, facility document review, and interview, the facility failed to develop written procedures for investigating allegations of abuse, misappropriation, and exploitation. The policy failed to include the procedures of a thorough investigations to include identification of staff responsible for the investigation; exercising caution in handling evidence that could be used in a criminal investigation; investigating different types of alleged violations; identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment had occurred; or providing complete and thorough documentation of the investigation. This affected 1 (Resident #190) of 1 abuse investigations reviewed. Findings include: A facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 10/2024, revealed, Residents have the right to be from abuse, neglect,…

    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 · Dcited before2025-03-06 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of facility policy, the facility failed to maintain a medication error rate of less than 5%. Observations of medication pass administration revealed 3 errors out of 30 opportunities which resulted in a 10% (percent) medication error rate. This affected 2 (Resident #21 and #90) of 2 residents observed during medication pass. Resident #21 was given one drop of artificial tears, instead of two drops. Resident #90 was given one drop of artificial tears, instead of two drops; and was administered magnesium 500 milligrams (mg), instead of magnesium 400 mg. Findings included: A facility policy titled, Administering Medications, revised in 02/2025, indicated, 4. Medications are administered in accordance with prescriber orders, including any required time frame. The policy also indicated, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1. An admission…

    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 before2025-03-06 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, facility document review, and facility policy review, the facility failed to have evidence that all allegations of abuse were thoroughly investigated for 1 (Resident #190) of 1 resident reviewed for abuse allegations. Findings included: A facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 10/2024, indicated, 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements. On 03/06/2025 at 10:20 AM, the Administrator stated the facility did not have a policy for abuse investigations. An admission Record indicated the facility admitted Resident #190 on 09/13/2024. According to the admission Record, the resident had a medical history that included diagnoses of post-traumatic stress disorder (PTSD), personal history of adult physical and sexual abuse, and diffuse traumatic brain…

    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 · E2023-10-19 · tag F0609 — failed to report abuse allegations — pattern
    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 record review and interview, it was determined, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA). In addition, report the results of all investigations to the SSA within 5 working days of the incident. Specifically, for 3 out of 33 sampled residents, exhibit 358 entity reports of two abuse allegations were not submitted to the SSA in a timely manner. In addition, exhibit 359 follow-up investigation report of one resident was submitted to the SSA six working days after the abuse incident was reported. Resident identifiers: 18, 24, and 27. Findings included: 1. Resident 18 was admitted to the facility on [DATE] with diagnoses which included pulmonary hypertension, morbid obesity, essential hypertension, type 2 diabetes mellitus, muscle weakness, hypothyroidism, major depressive disorder,…

    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 · E2023-10-19 · tag F0761 — failed to label and store drugs safely — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined, that the facility did not label all drugs and biological's used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, insulin pens were expired, open and available for use, and not labeled with an expiration date. In addition, a medication was not labeled with resident identifier information. Findings included: 1. On [DATE] at 7:45 AM, an observation was made of the south hallway medication cart with Registered Nurse (RN) 1, the following medication was located inside: a. A pre-filled pen of Ozempic was open and available for use. The pen had no resident identifier information and no open date could be seen. On [DATE] at 7:50 AM, an interview was conducted with RN 1. RN 1 stated that there was no name on the pen of Ozempic and he did not know who it belonged to. RN 1 was observed to then place the medication back in the medication…

    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 · Ecited before2023-10-19 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, it was determined, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 3 out of 33 sampled residents, staff members were observed to touch the resident's medications with bare hands during medication administration. Medications were replaced in medication cards after being touched with bare hands. Hand hygiene was not used. Medications were dropped on the medication cart and then administered to a resident. And the glucometer was not cleaned in between resident usage and trash was stored in the glucometer holding container. Resident identifiers: 14, 17, and 27. Findings included: On 10/18/23 at 8:34 AM, an observation was made of Registered Nurse (RN) 1 during morning medication administration. RN 1 was observed to place the index finger inside of the medication cup when picking up the medication cup from the medication cart and when…

    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 · Dcited before2023-10-19 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to report the results of all investigations to the State Survey Agency (SSA), within 5 working days of the incident. Specifically, for 1 out of 33 sampled residents, the facility did not submit the results of an allegation of neglect within 5 working days when a resident with severely impaired cognitive status was found outside of the facility. Resident identifier: 3. Findings included: Resident 3 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Alzheimer's disease, anxiety disorder, Pseudobulbar Affect, dysphagia, and hypertension. On 10/19/23, resident 3's medical record was reviewed. The admission Minimum Data Set assessment dated [DATE], revealed resident 3 had a Brief Interview for Mental Status (BIMS) score of 3. A BIMS score of 0 to 7 would suggest severe cognitive impairment. Exhibit 358 Initial Report…

    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 · D2023-10-19 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide 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, it was determined, that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 33 sampled residents, a resident's medications were not administered as ordered by the physician due to the medications not being available by the pharmacy. Resident identifier: 140. Findings included: Resident 140 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, rib fracture, atrial fibrillation, coronary artery disease, and kidney cancer metastatic. Resident 140's medical record was reviewed on 10/16/23. On 10/27/22 at 8:41 PM, a Nurses Note documented Note Text: Pt [Patient] is a new admit [admission] that came in this early afternoon. Pt is self ambulatory with walker. Admit diagnosis of fractured ribs post fall at home. Pt is a 5 day respite stay. Takes scheduled and PRN [as needed pain medication continuously. Pt has several abrasions throughout body from fall. Pt is A&O x4 [alert 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-19 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that medication error rates were not 5 percent or greater. Observations of 31 medication opportunities on 10/18/23, revealed two medication errors which resulted in a 6.45% medication error rate. Specifically, for 1 out of 33 sampled residents, an enteric coated (EC) medication was crushed and a resident was given an incorrect dose of a heart medication. Resident identifier: 14. Findings included: Resident 14 was initially admitted to the facility on [DATE] and readmitted in 9/15/23 with diagnoses which included metabolic encephalopathy, cardiogenic shock, chronic obstructive pulmonary disease, acute and chronic respiratory failure, type 2 diabetes mellitus, morbid obesity, anxiety, obstructive sleep apnea, anemia, dysphagia, and major depressive disorder. On 10/18/23 at 8:42 AM, an observation was made of Registered Nurse (RN) 5 during morning medication administration on the north and central hallways. RN 5 was observed to crush…

    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
Show the remaining 14 citations
  • Potential for harm · D2023-10-19 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined, the facility did not ensure that each resident's medical record included documentation that indicated that the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations; and that the resident either received the influenza and pneumococcal immunizations or did not receive the influenza and pneumococcal immunizations due to medical contraindications or refusal. Specifically, for 1 out of 5 sampled residents, a resident who requested to receive the pneumococcal vaccination did not receive it. Resident identifier: 3. Findings included: Resident was admitted to the facility on [DATE] with diagnoses which included hereditary and idiopathic neuropathy, Alzheimer's disease, scoliosis, pseudobulbar affect, anxiety, essential hypertension, hypercholesterolemia, and insomnia. Resident 3's medical record was reviewed on 10/16/23. A review of the immunization section of…

    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 · E2022-01-13 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor 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 interview and observation, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior environment for residents, staff and the public. Specifically, the resident's rooms were only cleaned once weekly and exterior areas were cluttered and dirty. Findings include: 1. On 1/10/21 at 2:17 PM, an observation was made of room [ROOM NUMBER]. Debris was observed on the floor throughout the room. A straw was observed under the south bed, and crumbs were observed under the bed. On the north side, crumbs were observed under the bed, and between the bed and the curtain. Drops of blood were observed on the sheets on the north bed. The residents in room [ROOM NUMBER] stated that housekeeping cleaned once weekly. On 1/12/21 at 12:35 PM, an observation was made of room [ROOM NUMBER]. Debris was observed on the floor of the room. Crumbs and a straw were observed under the south bed. The north bed had crumbs around the bed and drops of blood 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 · E2022-01-13 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    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 7 of 30 sample residents, that the facility did not assess each resident using the quarterly review instrument specified by the State and approved by Center for Medicare services not less frequently than once every 3 months. Specifically, residents quarterly Minimum Data Set (MDS) were not completed timely. Resident identifiers: 3, 4, 6, 7, 10, 11, and 25. 1. Resident 6 was initially admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses which included, Friedreich ataxia, toxic encephalopathy, scoliosis, unspecified convulsions, poisoning by iron and its compounds, intentional self-harm, muscle weakness, major depressive disorder, generalized anxiety disorder and borderline personality disorder. On 1/11/22, the medical record of resident 6 was reviewed. A MDS assessment with an assessment reference date (ARD) of 12/5/21 was not completed and was 25 days overdue. 2. Resident 3 was admitted to the facility on [DATE] with diagnoses…

    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 F0684 — failed to provide proper treatment and quality of care — pattern
    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 observation, interview and record review it was determined that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 4 of 30 sample residents. Specifically, bandages were not changed as charted, a COVID-19 positive resident was not monitored for additional needs, and care coordination was poor with outside facilities. In addition, residents were not clean when attending dialysis. Resident identifiers: 12, 32, 37 and 97. Findings include: 1. Resident 37 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, hsitory of transient ischemic attack (TIA), scoliosisi, protein/calorie malnutrition, chronic kidney disease, type II diabetes, and fracture with healing following surgery. On 1/10/22 at 2:02 PM, resident 37 was observed wearing bandages on her right leg. Resident 37 was interviewed and stated that she had not had…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-01-13 · tag F0698 — failed to provide proper dialysis care — pattern
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined for 2 of 30 sample residents that the facility did not ensure that a resident who required dialysis received such services consistent with professional standards of practice. Specifically, there was no ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Resident identifiers: 33 and 97. Findings include: 1. Resident 33 was admitted to the facility on [DATE] with diagnosis which included, type II diabetes mellitus with neuropathy, severe morbid obesity, end stage renal disease, generalized muscle weakness, congestive heart failure, and dependence on renal dialysis. On 1/11/22, resident 33's medical record was reviewed. Physician's orders revealed the following: a. Dialysis to be conducted every Monday, Wednesday and Friday. b. Post dialysis weight. c. Check fistula in left forearm for color, warmth and edema. d. Check AV (arteriovenous) shunt for presence of bruit and thrill every shift. If negative notify…

    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 · E2022-01-13 · 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 record review and interview, it was determined, for 4 of 30 sample residents, that the facility did not maintain medical records on each resident that were complete and accurately documented. Specifically, a resident's medical record contained a progress note about a different resident, a resident's medical record was missing blood glucose measurements, and two residents had incomplete immunization records. Resident identifiers 10, 14, 21, and 31. Findings include: 1. Resident 31 was admitted to the facility on [DATE] with a diagnoses that included chronic obstructive pulmonary disease, gout, chronic diastolic heart failure, chronic kidney disease, and type 2 diabetes mellitus. Resident 31's medical record was reviewed on 1/12/22. A progress note dated 11/11/21 included information about a different resident seen for a wound on his lower back. An interview with the Corporate Resource Nurse was conducted on 1/13/22. The Corporate Resource Nurse stated that the progress note dated 11/11/21 regarding 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.

    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not conduct COVID-19 testing based on the criteria for conducting testing of asymptomatic individuals, such as the community transmission rate of COVID-19. Specifically, unvaccinated staff members were not tested twice a week when the community transmission rate was high. This occurred for 5 out of 5 sampled staff members. Findings include: Centers for Medicare and Medicaid Services (CMS) Memo QSO-20-38-NH, revised on 9/10/21, reads, The facility should test all unvaccinated staff at the frequency prescribed in the Routine Testing table [High = Twice a week] based on the level of community transmission reported in the past week. The Utah County transmission rates for December 2021 and January 2022 were high. On 1/13/22 staff testing for COVID-19 was reviewed with the Corporate Resource Nurse/Infection Preventionist. Five staff members were selected from the facility's list of staff, who were unvaccinated for COVID-19. 1. Certified Nursing Assistant (CNA) 3…

    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 · E2022-01-13 · tag F0887 — pattern
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not maintain documentation of when residents did not receive the COVID-19 vaccine due to medical contraindication or refusal. Specifically there was no documentation of a resident refusing the COVID-19 vaccine due to contraindications communicated to the resident by her physician. Additionally, there was no documentation of a resident being offered, having received or refusing the COVID-19 vaccine. This occurred for 2 out of 30 sample residents. Resident identifiers: 14 and 21. Findings include: 1. Resident 14 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, osteoporosis, major depressive disorder, and pain. On 1/13/22, resident 14's medical record was reviewed. There was no documentation of resident 14 being offered, having received or refusing the COVID-19 vaccine. On 1/13/22 at 1:49 PM, an interview was conducted with the facility's Assistant Director of Nursing (ADON). The ADON stated he could not find any…

    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 F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents had the right to make choices about aspects of his or her life in the facility that were significant to the resident; nor did the facility ensure that residents had the right to choose activities consistent with his or her interests for 1 of 30 sample residents. Specifically, a resident was not able to shower on the days he requested. Resident identifier: 33. Resident 33 was admitted to the facility on [DATE] with diagnosis which included, type II diabetes mellitus with neuropathy, severe morbid obesity, end stage renal disease, generalized muscle weakness, congestive heart failure, and dependence on renal dialysis. Findings include: On 1/11/21 at 9:35 AM, an interview was conducted with resident 33. Resident 33 stated it was difficult to get anyone to answer the call light promptly. Resident 33 stated that when the staff did come they are usually helpful. Resident 33 stated showers are not a huge deal, he would just like them to be…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-13 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    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 30 sample residents, that the facility did not conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity, not less than once every 12 months. Specifically, resident's annual Minimum Data Set (MDS) assessments were not completed every 12 months. Resident identifiers: 4, 97, and 147. 1. Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included quadriplegia, acute respiratory failure with hypoxia, and vascular dementia. Resident 4's electronic medical record review was completed on 1/10/2022. Resident 4's MDS assessments were reviewed and revealed an Annual MDS dated [DATE]. There was an in progress annual MDS date 11/16/2021. The MDS was not completed or submitted. 2. Resident 147 was admitted to the facility on [DATE] with a diagnoses that included cerebral infarction, dysphagia, and unspecified dementia. Resident 147's electronic medical…

    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 · D2022-01-13 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    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 develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care for 1 of 30 sample residents. Specifically, a resident with many issues, including intravenous antibiotics and dialysis did not have a care plan that included their major issues. Resident identifier: 97. Findings include: Resident 97 was admitted to the facility on [DATE] with no listed diagnoses. Resident 97 was prescribed an antibiotic, cholesterol medication, and was receiving dialysis. On 1/10/22 at 3:15 PM, resident 97 was interviewed. Resident 97 stated that staff did not provide much assistance to him. Resident 97's medical record was reviewed on 1/10/22. The care plan contained one entry, for a nutritional problem due to septic arthritis and dialysis use. Resident 97 was on a therapeutic diet. Within 48 hours of…

    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 · D2022-01-13 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 1 of 30 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident with multiple issues did not have a comprehensive care plan. Resident identifier: 97. Findings include: Resident 97 was admitted to the facility on [DATE] with no listed diagnoses. Resident 97 was prescribed an antibiotic, cholesterol medication, and was receiving dialysis. On 1/10/22 at 3:15 PM, resident 97 was interviewed. Resident 97 stated that staff did not provide much assistance to him. Resident 97's medical record was reviewed on 1/10/22. Resident 97's care plan contained one entry, for a nutritional problem due to septic arthritis and dialysis use. Resident 97 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-01-13 · tag F0812 — failed to store, cook, and serve food safely — isolated
    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, 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, a refrigerator for resident's food was not maintained by staff members. Findings include: On 1/11/22 at 9:15 AM, resident 19 stated that he had food that went missing out of the resident's refrigerator. On 1/11/22 at 1:40 PM, an observation was made of the residents' refrigerator. A stainless steel refrigerator was located in the southeast corner of the dining room. A digital thermometer readout was visualized on the front of the refrigerator. The temperature stated 34 degrees. An interview was conducted with the dietary manager (DM) who stated that the refrigerator was maintained by the certified nursing assistants (CNAs) and the kitchen staff did not maintain the refrigerator, clean it, or monitor the temperatures. The DM stated that residents could access food in the refrigerator at any time and retrieve their food. A sign on the refrigerator stated: Residents, staff…

    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 · D2022-01-13 · tag F0838 — failed to assess facility resources and resident needs — isolated
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update the assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there was, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Specifically, the facility assessment was incomplete. Findings include: On 1/13/2022 the facility assessment provided by the Administrator was reviewed. The facility assessment was titled Facility Assessment Tool and did not include the following: a. Information describing the process to make admission or continuing care decisions regarding caring for residents with conditions that the facility is less familiar with and have not previously supported. b. Ethnic, cultural, or religious factors or personal resident preferences were not addressed. No statement that indicated…

    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

“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

$11,992 in federal fines across 1 penalty.

  • $11,992 — penalty dated 2023-10-19

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 CASCADES HEALTHCARE — 19 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 4 of 51.9+2.1 vs chain
Health inspection 4 of 51.7+2.3 vs chain
Staffing 2 of 52.1-0.1 vs chain
Quality measures 4 of 54.1≈ chain avg
The other 18 homes this chain runs (chain average 1.9★, 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 / managerTypeRoleSince
BARNEY, JANETTIndividualMANAGING CONTROL - GOVERNING BODYsince 09/18/2018
BROWN, GARYIndividualMANAGING CONTROL - GOVERNING BODYsince 09/18/2018
LANGFORD, SCOTTIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2016
MCSPADDEN, DARINIndividualMANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
OAKDEN, RICHARDIndividualMANAGING CONTROL - GOVERNING BODYsince 09/18/2018
ROBINSON, MATTHEWIndividualMANAGING CONTROL - GOVERNING BODYsince 09/18/2018
SMITH, VALIndividualMANAGING CONTROL - GOVERNING BODYsince 09/18/2018
WHITE, CRAIGIndividualMANAGING CONTROL - GOVERNING BODYsince 09/18/2018
CASCADES HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
BAIRD, GREGORYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
MARTIN, JOSHUAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/28/2025
BEAVER VALLEY HOSPITALOrganizationADP OF THE SNFsince 09/18/1999

CMS files one row per role, so the 19 rows in the source record cover these 12 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.

2 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.

$6.0M
Net patient revenuemost recent cost report
-0.6%
Operating marginrevenue minus expenses
$641K
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 70%Medicare 3%Other / private 27%

About 70% 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 $641K 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 2024. 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

$383per resident / day
operating cost
$11,649per month
≈ monthly operating cost
$381per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). 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

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.

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 465090. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-06, 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.

What to do next