Orem Rehabilitation and Nursing Center

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

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.

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.

49.8% 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 37 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 30.0% 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 20 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 0.98 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% 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.

Staffing

How full it usually is: this home is certified for 120 beds and averages 77.4 residents a day — about 65% occupied, or roughly 43 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.45 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.88 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 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 2.99 hrs/resident/day on weekends vs 3.63 on weekdays — 18% thinner on weekends. RN hours go from 0.98 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

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.

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

29 citations, most serious first. The 15 most serious are shown; the remaining 14 are one tap away and print in full.

• Immediate jeopardy · K2023-07-18 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined for 8 out of 40 sampled residents, that the facility failed to protect residents form abuse. Specifically, residents were sexually abused without ongoing interventions to prevent further abuse. Additionally, the facility had prior knowledge of the alleged perpetrators sexual behaviors and the facility failed to provide protection for the residents thereby allowing ongoing access to the residents by the alleged perpetrator. Finally, victims of the sexual abuse exhibited crying and expressed recurring fear of the perpetrator. Based on the resident(s) behavior, it can be determined that the resident(s) experienced psychosocial harm as a result of the sexual abuse. This identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifiers: 3, 10, 18, 24, 26, 31, 34, and 136. NOTICE On 7/12/23 at 5:00 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2023-07-18 · tag F0610 — failed to investigate and act on abuse reports — pattern
  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, for 9 out of 40 sampled residents, that in response to allegations of abuse the facility failed to have evidence that all alleged violations were thoroughly investigated and further potential abuse was prevented. Specifically, the facility initial entity reports and final investigation reports filed with the State Survey Agency (SSA) contained incomplete summaries of incidents of sexual abuse, and the facility did not have supporting documentation of the summaries that were provided to the SSA. Additionally, not all reported incidents of alleged sexual abuse had evidence that suggested they were investigated by the facility. Multiple instances of resident to resident sexual abuse occurred with an insufficient investigation. This identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Furthermore, the facility did not conduct an independent investigation into a resident's missing Fentanyl patch but instead relied on 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-05-22 · tag F0603 — failed to not confine residents against their will — isolated
  Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
  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 7 sampled residents, that the facility did not ensure that the resident had the right to be free from abuse including involuntary seclusion. Specifically, the resident was seeking egress from a room and was denied the right to exit by facility staff. Resident identifier 2. Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, congestive heart failure, atrial flutter, type II diabetes mellitus, chronic kidney disease, morbid obesity, chronic pain, difficulty with walking, polyneuropathy, hypertension, obstructive sleep apnea, and thrombocytopenia. Resident 2 was discharged from the facility on 3/30/24. On 12/30/23, resident 2's Minimum Data Set (MDS) assessment documented that the resident had a Brief Interview for Mental Status (BIMS) score of 15, which would indicate that the resident was cognitively intact. The assessment documented that resident 2 required an extensive one-person…

  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
• Actual harm · G2023-07-18 · tag F0835 — failed to run the facility competently — isolated
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple residents were identified to be in Immediate Jeopardy for allegations of sexual abuse. Resident identifiers: 3, 10, 18, 24, 26, 31, 34, and 136. Findings included: 1. Based on observation, interview and record review, it was determined for 8 out of 40 sampled residents, that the facility failed to protect residents form abuse. Specifically, residents were sexually abused without ongoing interventions to prevent further abuse. Additionally, the facility had prior knowledge of the alleged perpetrators sexual behaviors and the facility failed to provide protection for the residents thereby allowing ongoing access to the residents by the alleged perpetrator. Finally, victims of the sexual abuse exhibited crying and expressed recurring fear of the perpetrator. Based on the resident(s) behavior, it can 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-07-18 · tag F0867 — failed to act on quality-improvement findings — isolated
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The facility did not develop and implement policies addressing how they would use a systematic approach to determine underlying causes of problems impacting larger systems; how they would develop corrective actions that would be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and how the facility would monitor the effectiveness of its performance improvement activities to ensure that improvements were sustained. Specifically, multiple residents were identified to be in Immediate Jeopardy for allegations of sexual abuse. Resident identifiers: 3, 10, 18, 24, 26, 31, 34, and 136. Findings included: 1. Based on observation, interview and record review, it was determined for 8 out of 40 sampled residents, that the facility failed to protect residents form abuse. Specifically, residents were sexually abused without ongoing…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-05-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  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 observation, interview, and record review it was determined, for 2 of 28 sample residents, that 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, two high fall risk residents did not have interventions put in place after multiple falls. Resident identifiers: 18 and 69. Findings included: Resident 69 was admitted to the facility on [DATE] with diagnoses which included but were not limited to dementia, hypotension, muscle weakness, morbid obesity, unsteadiness on feet, and need for assistance with personal care. Resident 69's medical record was reviewed 4/28/25 through 5/1/25. A Quarterly Minimum Data Set (MDS) dated [DATE] documented resident 69 was a one person physical assist with transfers, toileting and bed mobility. On 12/30/24, resident 69 was documented as a High Fall risk. A care plan focus dated 6/19/21 with a revision date 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-05-01 · tag F0728 — failed to protect against nurse-aide misconduct — pattern
  Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility did not ensure that any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, was competent to provide nursing and nursing related services; and completed a training and competency program, or a competency evaluation program approved by the State. Specifically, Nurse Aides (NA) were employed at the facility, for over 4 months without completion of training and competency evaluation program. Findings include: On 4/30/25 NA 1's employee record was reviewed. NA 1 was hired on 9/3/24 as a NA. NA 1 was still employed as a NA and the last day worked was on 4/29/25. On 4/30/25 NA 2's employee record was reviewed. NA 2 was hired on 9/9/24 as a NA. NA 2 was still employed as a NA and the last day worked was on 4/11/25. On 4/30/25 NA 3's employee record was reviewed. NA 3 was hired on 5/3/25 and received his certification on 3/18/25. NA 3's last day of work as a NA at the facility was 3/16/25. On 4/30/25 NA 4's employee record was reviewed. NA 4 was hired on 9/4/24. NA 4 was still employed as a NA…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-05-01 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure 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, the facility did not provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, for 7 out of 28 sampled resident, residents complained of the quality and temperature of the food, food was being fortified with a squirt of cold milk or splash of butter on the already prepared food, a test tray was not palatable and the food was cold. Resident identifiers: 19, 29, 35, 39, 41, 47 and 59. Findings include: 1. On 4/28/25 at 9:57 AM, an interview was conducted with resident 47. Resident 47 stated that she was on a specialized diet of minced and moist food. Resident 47 stated that the food tasted pretty gross. Resident 47 stated that she was given mashed potatoes in the shape of a hot dog that tasted bad and looked awful. 2. On 4/28/25 at 10:00 AM, an interview was conducted with resident 59 who stated the food was usually cold. 3. On 4/28/25 at 10:29 AM, an interview was conducted with resident 39. Resident 39 stated that sometimes the food served at the facility was pretty bad. 4. On 4/28/25 at…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-05-01 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were unlabeled and undated food items stored in the kitchen, there was food stored on the floor in the kitchen, meat was improperly stored in the walk-in refrigerator, staff cellphones and beverages were stored in food preparation areas, and staff did not serve food in a hygienic manner. Findings Include: On 4/28/25 at 8:41 AM, an initial observation of the kitchen was conducted. On 4/28/25 at 8:47 AM, an observation was made of the walk in refrigerator. There was an undated, unlabeled liquid in a 22 quart container. There was an opened box of bacon stored on a shelf above open boxes of bananas and oranges. There were multiplied carafes of juice that were not labeled or dated on the top shelf of the refrigerator. On 4/28/25 at 8:50 AM, an observation was made of the kitchen's dry storage room. There was a #10 can of beets sitting on the floor of the dry storage. There 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.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-01 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
  Reasonably accommodate the needs and preferences of 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 the facility failed to provide reasonable accommodations of needs and preferences except when to do so would endanger the health or safety of resident or other residents for 1 of 28 sampled residents. Specifically, a resident was not provided timely appointments to referred specialists for hand contractures and foot drop. Resident identifier: 41. Findings include: On 4/28/25 at 2:27 PM, an interview was conducted with resident 41. Resident 41 stated that she had to ask three different times to get an appointment with a specialist, she just barely got an appointment for the orthopedic hand surgeon. Resident 41 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, type 2 diabetes mellitus, other reduced mobility, and major depressive disorder. Review of resident 41's records was completed on 4/28/25 through 5/1/25. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 41 had a Brief Interview of Mental…

  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 · D2025-05-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility did not ensure that each resident who needed respiratory care was provided such care consistent with professional standards of practice. Specifically, 1 out of 28 sample residents, did not have an order to change the oxygen tubing and humidifier. Resident identifier: 47 Findings included: Resident 47 was admitted to the facility on [DATE] with diagnoses which included, acute respiratory failure with hypoxia, epilepsy, and subarachnoid hemorrhage. On 4/28/25 at 9:57 AM, a concurrent interview and observation was made with resident 47. Resident 47 was observed in bed with a nasal cannula attached to an oxygen concentrator delivering 3 liters of oxygen. The nasal cannula was undated. Resident 47's portable oxygen tank had a nasal cannula attached that was undated and wrapped around the left wheel of the resident's wheelchair. Resident 47 stated that she did use oxygen. On 4/29/25 at 10:46 AM, an observation was made of resident 47's oxygen cannulas.…

  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 · D2025-05-01 · tag F0732 — isolated
  Post nurse staffing information every day.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, the facility did not have the nurse staffing information posted. The facility must post the nurse staffing data on a daily basis at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Specifically, nurse staffing information was out of date and not posted on weekends. Findings include: On 4/28/25 at 8:31 AM, during the initial tour of the facility, the nurse staff posting was dated 4/23/25. On 4/30/25 at 11:52 AM, an interview was conducted with the Administrator (ADM). The ADM stated that the nurse staffing information was posted by the receptionist. On 4/30/25 at 11:55 AM an interview was conducted with the receptionist. The receptionist stated that she was out sick on 4/24/25 and 4/25/25 and no one else posted the daily staffing information during her absence. The receptionist stated that she worked Monday through Friday and that the daily nurse staffing information was not posted on weekends because the weekend receptionist did not know how. On 5/1/25 at 8:15 AM, a follow-up interview 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-01 · tag F0775 — isolated
  Keep complete, dated laboratory records in the resident's record.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined for, 1 out of 28 sample residents, that the facility did not file, in the resident's clinical record, laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, a resident's laboratory results were not located in the electronic medical records. Resident identifier: 30 Findings included: Resident 30 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes, congestive heart failure, essential hypertension, schizoaffective disorder, bell's palsy, anxiety disorder, and depression. Resident 30's medical record was reviewed 4/28/25 through 5/1/25. A physician's order, dated 9/9/24, ordered a Complete Blood Count (CBC) every day shift starting on the 10th and ending on the 10th every month for Plavix/Eliquis Use. A physician's order, dated 4/16/25, ordered a CBC one time only related to . possible UTI [urinary tract infection]. No laboratory results could be located on resident 30 ' 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-01 · tag F0881 — failed to use antibiotics responsibly — isolated
  Implement a program that monitors antibiotic use.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined, for 2 or 28 sampled residents, the facility failed to keep an antibiotic stewardship program that included antibiotics use protocols and a system to monitor all antibiotic use for all residents. Specifically, residents with orders for prophylaxis antibiotics were not monitored for their antibiotic use. Resident identifier: 23 and 28. Findings include: 1. Resident 23 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included acquired deformity of left lower leg, type 2 diabetes mellitus, bipolar disorder, and personal history of urinary tract infections (UTI). Review of resident 23's records was completed on 4/29/25 through 5/1/25. A physician's order dated 10/20/24 documented, Keflex Oral Capsule 500 milligrams (mg) (Cephalexin) Give 1 capsule by mouth at bedtime for Prophylaxis for UTI. 2. Resident 28 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included borderline personality 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-01 · tag F0602 — failed to protect residents from theft of their belongings — isolated
  Protect each resident from the wrongful use of the resident's belongings or money.
  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 prevent misappropriation of a resident's medications for 1 of 28 sampled residents. Specifically, a resident had a nurse tell him he was getting his pain medication but was replacing it with another medication on multiple occasions. Resident identifier: 170. Findings included: Resident 170 was admitted to the facility on [DATE] and discharged on 9/27/24 with diagnoses which included cerebral infarction due to embolism, acute and chronic respiratory failure, and chronic pain syndrome. Review of resident 170's records was completed on 4/28/25 through 5/1/25. A comprehensive Minimum Data Set (MDS) dated [DATE] revealed that resident 170 had a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. A grievance placed on 9/9/24, by resident 170 to the Director of Social Services (DSS) revealed, [Resident 170] states that he has some concerns about his medications, he feels that he is being given the wrong…

  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

“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.

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 →

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

CMS files one row per role, so the 16 rows in the source record cover these 11 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.

6 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 71% 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 $1.1M paid to related parties — landlords or management companies under common ownership — equal to about 12% 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

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