Parkdale Health and Rehab
250 East 600 North, Price, UT 84501 · For profit - Corporation · 58 certified beds · (435) 637-2621 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $6,351 in federal fines (most recent 2023-09-05)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- nursing-staff turnover (61%) runs well above the national median (45%)
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 18.9% | 11.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.8% | 3.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.2% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 4.1% | 1.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 31.2% | 16.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 4.1% | 2.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 26.7% | 15.1% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 12.2% | 25.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.7% | 3.9% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 29.8% | 21.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 26.9% | 14.2% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 0.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.0% | 91.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.2% | 16.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.9% | 11.6% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.22 | 1.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.05 | 1.43 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
54.9% 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 86 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 64.4% 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 45 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 0.35 therapist hours per resident per day in 2026Q1 — more than 59% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 3% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 54.9%CMS range 47.4–63.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.4%CMS range 5.9–15.1 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 64.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 53.3% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 60.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.8% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.2%CMS range 3.2–11.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.24 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 58 beds and averages 29.6 residents a day — about 51% occupied, or roughly 28 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 3.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.38 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.06 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 2.95 hrs/resident/day on weekends vs 3.73 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.57 to 0.93 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 61% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 12 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · G2022-12-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure a resident with pressure ulcers received the necessary treatment and services, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, for 1 out of 20 sampled residents, a resident that developed pressure ulcers on both heels did not have the treatment implemented according to the physician's orders. In addition, the resident's left anterior pressure ulcer developed an infection. Resident identifier: 80. Findings included: Resident 80 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included, but were not limited to, aftercare following joint replacement surgery, encounter for removal of internal fixation device, presence of left artificial hip joint, acute respiratory failure, moderate protein-calorie malnutrition, difficulty in walking, benign prostatic hyperplasia, obstructive and reflux uropathy, hypertension, dementia, and acute kidney failure. Resident 80's 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.
- Actual harm · Gcited before2021-05-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 2 of 19 sample residents, that the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, facility staff did not obtain additional medical care for four days after a resident fell causing a broken leg above a recent artificial knee. This delay was determined to have occurred at a harm level. Additionally, a resident was transferred by a Certified Nursing Assistant (CNA) who did not lock the wheelchair wheels during the transfer causing the resident to fall. Resident identifiers: 11 and 22. Findings include: 1. Resident 22 was admitted to the facility on [DATE] with diagnoses which included left total knee replacement, osteoarthritis of the left knee, a wedge compression fracture of T11-T12 vertebra, anxiety disorder, osteoporosis, developmental disorder, and tremor. On 5/17/21 at 3:20 PM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-05-18 · tag F0867 — failed to act on quality-improvement findings — widespreadSet 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 interviews, document review, and facility policy review, the facility failed to implement a quality assurance and performance improvement program to evaluate and monitor resident falls in the facility. This deficient practice had the potential to affect all residents who currently resided in the facility. Findings included: A facility policy titled, Quality Assessment and Assurance Plan, revised in December 2009, revealed, This facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assessment and Assurance Program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems. Policy Interpretation and Implementation The primary purposes of the Quality Assessment and Assurance Plan are: 1. To provide a means to identify and resolve present and potential negative outcomes related to resident care and safety. Per the policy, 2. The Administrator is responsible for assuring that this facility's Quality Assessment and Assurance Program complies with federal, state, and local…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-18 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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
Based on observations, interviews, record reviews, and facility policy review, the facility failed to develop a care plan to address the supplemental oxygen usage for 4 (Residents #1, #8, #11, #23) of 6 sampled residents reviewed for respiratory care and a care plan to address the fall status of 1 (Resident #16) of 4 sampled residents reviewed for accidents. Findings included: A facility policy titled, Care Plans, Comprehensive Person - Centered, revised in January 2024, revealed, A comprehensive, person-centered care plan that includes measurable objective and timetables to meet resident's physical, psychological and functional needs is developed and implemented for each resident. The policy specified, 1. An admission Record revealed the facility readmitted Resident #23 on 04/05/2024, with diagnoses to include acute respiratory failure with hypoxia and congestive heart failure. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/12/2024, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-18 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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
Based on interviews, record reviews, and facility policy review, the facility failed to conduct neurological assessments following unwitnessed falls for 2 (Resident #16 and Resident #28) of 4 sampled residents reviewed for accidents. Findings included: A facility policy titled, Neurological Assessment, revised in October 2010, revealed, The purpose of this procedure is to provide guidelines for a neurological assement:1) upon physician order; 2) when following an unwitnessed fall; 3) subsequent to a fall with a suspected head injury; or 4) when indicated by resident condition. 1. An admission Record revealed the facility originally admitted Resident #16 on 08/11/2022, with diagnoses to include abnormal posture, hypertension, and personal history of traumatic brain injury. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The MDS revealed the resident required substantial/maximal assistance with sit to stand,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to ensure adequate supervision was provided to maintain safety and prevent potential injury during smoke breaks for 1 (Resident #1) of 4 sampled residents reviewed for accidents. On 05/14/2024 at 11:57 AM, Resident #1 was smoking outside in the designated smoking area with a portable oxygen tank on the back of their wheelchair and, a nearby propane tank. The facility further failed to ensure 2 (Resident #16 and Resident #28) of 4 sampled residents reviewed for accidents received adequate supervision and/or assistive devices to prevent falls. Findings included: 1. A facility policy titled, Smoking Policy - Residents, revised in August 2022 revealed, 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. Electronic cigarettes are permitted in designated areas only. Smoking is not allowed inside the facility under any circumstances. 3. Oxygen use is prohibited in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — patternProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
3. An admission Record revealed the facility admitted Resident #11 on 04/16/2024, with diagnoses to include chronic obstructive pulmonary disease, asthma, obstructive sleep apnea, pneumonia, and bronchitis. An admission Minimum Data Set (MDS), with an Assessment References Date (ARD) of 04/22/2024, revealed Resident #11 used oxygen therapy. Resident #11's Order Summary Report, for the timeframe 04/16/2024 to 05/31/2024, did not reveal a physician's order for the resident's use of supplemental oxygen. On 05/13/2024 at 11:50 AM, Resident #11 was observed lying in bed with oxygen tubing on and an oxygen concentrator in the on position, set at two liters per minute. On 05/18/2024 at 9:53 AM, Resident #11 was observed in the hall by the nurses' station. The resident had oxygen tubing on and an oxygen concentrator in the on position, set at two liters per minute. During an interview on 05/14/2024 at 3:12 PM, the Director of Nursing (DON) stated Resident #11 received supplemental oxygen ever since they admitted to the facility. During an interview on 05/14/2024 at 3:13 PM, the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-05-18 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
4. An admission Record revealed the facility admitted Resident #21 on 03/21/2023, with a diagnosis to include shortness of breath. Per the admission Record, on 05/10/2024, Resident #21 received a diagnosis of chronic obstructive pulmonary disease and acute respiratory failure with hypoxia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/10/2024, revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident used oxygen therapy. Resident #21's care plan, initiated on 03/29/2023, revealed the resident had shortness of breath. Resident #21's Order Summary Report, that contained active orders as of 05/17/2024, revealed an order dated 08/29/2023, for ipratropium-albuterol inhalation solution, inhale three milliliters orally by way of nebulizer every six hours as needed for chronic obstructive pulmonary exacerbation. On 05/13/2024 at 10:05 AM and 05/16/2024 at 9:00 AM, Resident #21's nebulizer was observed uncovered on the resident's nightstand.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-18 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and facility policy review, the facility failed to notify the physician after a resident sustained a fall for 1 (Resident #16) of 4 sampled residents reviewed for accidents. Findings included: A facility policy titled, Change in a Residents Condition or Status, revised in May 2024, revealed, Policy Statement Our facility promptly notifies the resident, his or her attending physician, and resident representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation 1. The nurse will notify the resident's attending physician or physician on call when there has been a(n): a. accident or incident involving the resident. An admission Record revealed the facility originally admitted Resident #16 on 08/11/2022, with diagnoses to include abnormal posture, hypertension, and personal history of traumatic brain injury. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/02/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 13, which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-05-18 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record reviews, and facility policy review, the facility failed to ensure an appropriate diagnosis was obtained for all psychotropic medications ordered for 2 (Resident #7 and Resident #11) of 5 sampled residents reviewed for unnecessary medication, psychotropic medications, and medication regimen review. Findings included: A facility policy titled, Psychotropic Medication Use, dated July 2022, revealed, Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation 1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. 1. An admission Record revealed the facility admitted Resident #7 on 04/01/2024, with diagnoses of chronic respiratory failure with hypoxia, type 2 diabetes mellitus, protein-calorie malnutrition, unsteadiness on feet, encephalopathy, pneumonia, end stage renal disease, arteriovenous fistula, bipolar disorder, and dependence on renal dialysis. An admission Minimum Data Set (MDS), with an Assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-05-18 · tag F0944 — widespreadConduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and facility policy review, the facility failed to conduct mandatory training for all staff on the facility's quality assurance and performance improvement (QAPI) program. This deficient practice affected all residents who currently resided in the facility, Findings included: A facility policy titled, Quality Assessment and Assurance Plan, revised in December 2009, revealed, This facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assessment and Assurance Program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, and resolve identified problems. The policy did not address staff training on the facility's QAPI program. During an interview on 05/17/2024 at 5:00 PM, the Director of Nursing (DON) stated there was not specific staff training on QAPI. During an interview on 05/18/2024 at 9:15 AM, the Administrator stated there had not been any staff training on QAPI. During an interview on 05/18/2024 at 9:35 AM, [NAME] Aide #17 stated he was not sure what QAPI was and had not received 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.
- Potential for harm · E2023-12-12 · tag F0609 — failed to report abuse allegations — patternTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property for 4 of 7 sample residents were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. In addition, the facility did not report the results of all investigations to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 18 citations
- Potential for harm · E2023-12-12 · tag F0610 — failed to investigate and act on abuse reports — patternRespond 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, the facility did not ensure that all allegations of abuse were thoroughly investigated. Specifically, the facility completed a form 359 as a summary for allegations of abuse, but did not have additional evidence of the complete investigation for 4 of 7 sample residents. Resident identifiers: 1, 2, 3 and 7. Findings include: 1. Resident 7 was admitted to the facility on [DATE] with diagnoses that included history of falls, aftercare following joint replacement surgery, scalp contusion, polyneuropathy, and protein calorie malnutrition. Resident 7's medical record was reviewed on 12/12/23 On 9/13/23 at 8:07 PM, a nurses note indicated that, RN (Registered Nurse) was walking down the hallway and [resident 7] was sitting on her couch asking for help RN entered her room and asked what she needed help with she states she needs help to her bed she then told the RN that she was brushing her hair and fell to the floor but was able to get herself to her couch. RN assessed her and found…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2022-12-15 · tag F0885 — failed to notify residents/families about COVID-19 — widespreadReport COVID19 data to residents and families.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to inform residents, resident representatives, and resident families of the occurrence of a single confirmed infection of coronavirus disease of 2019 (COVID-19), or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other by 5:00 PM the next calendar day. Specifically, three facility staff members tested positive for COVID-19 and residents, resident representatives, and resident families were not notified of the outbreaks. Findings included: Review of the Facility COVID Testing - Employee Outbreak tracking log revealed the following: a. On 11/17/22, the Administrator (ADM) tested positive. b. On 11/21/22 Therapy 1 tested positive [Note: The Resident Advocate (RA) tested positive on 10/26/22, the results were not documented on tracking log.] Resident progress notes were reviewed for residents 1, 10, 12, 13, 19, 23, and 24. No documentation was found that indicated residents, resident representatives, or resident families were notified of the COVID-19 outbreaks on 10/26/22…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-12-15 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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, 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. Specifically, for 3 out of 20 sampled residents, a resident with orders to follow up with the Orthopedic Surgeon two weeks after discharge from the hospital did not have a follow up and the surgical staples were not removed until four weeks after discharge from the hospital. A resident with a nephrostomy tube did not receive wound care as ordered by the Physician Assistant (PA) professional wound specialist and a resident with a rash and itchy skin was not treated. Resident identifiers: 12, 15, and 80. Findings included: 1. Resident 80 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis which included, but were not limited to, aftercare following joint replacement surgery, encounter for removal of internal fixation device, presence of left…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-12-15 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop 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, the facility did not ensure that each resident was offered an influenza and/or pneumococcal immunization and that the medical record included documentation that the resident either received the immunization or did not due to medical contraindications or refusal. Specifically, for 3 out of 20 sampled residents, residents that had consented to the pneumococcal immunization did not have documentation that the pneumococcal immunization was provided. In addition, a resident that had consented to the influenza immunization did not have documentation that the influenza immunization was provided. Resident identifiers: 19, 23, and 24. Findings included: 1. Resident 19 was admitted to the facility on [DATE] with diagnoses which included hypothyroidism, altered mental status, and essential hypertension. On 12/12/22, resident 19's medical record was reviewed. A signed pneumococcal immunization consent form dated 7/20/22, was located in resident 19's medical record but both the consent…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-12-15 · tag F0887 — patternEducate 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 ensure the resident's medical record included documentation that indicates, at a minimum, the following: that the resident or resident representative was provided education regarding the benefits and potential risks associated with the Coronavirus disease of 2019 (COVID-19) vaccine; each dose of COVID-19 vaccine administered to the resident; or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Specifically, for 5 out of 20 sampled residents, the facility did not provide the resident or resident representative with education of the benefits and potential risks associated with the COVID-19 vaccination. In addition, the resident's medical record did not include documentation regarding the residents' COVID-19 vaccination refusal or acceptance. Resident identifiers: 14, 15, 19, 23, and 24. Findings included: 1. Resident 14 was admitted to the facility on [DATE] with diagnoses that included non-ST-elevation…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-15 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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 the residents right to participate in the development and implementation of his or her person-centered plan of care. Specifically, for 1 out of 20 sampled residents, a resident that was admitted to the facility on [DATE], had not had a care conference and the resident was unsure what the plan of care consisted of. Resident identifier: 16 Findings included: Resident 16 was admitted to the facility on [DATE] with diagnoses which include acute osteomyelitis (left ankle and foot), chronic obstructive pulmonary disease, dementia, major depressive disorder, schizoaffective disorder, post-traumatic stress disorder, generalized anxiety disorder, cellulitis of left lower limb, peripheral vascular disease, chronic systolic heart failure, adult failure to thrive, muscle weakness, essential hypertension, and malignant neoplasm of unspecified part of unspecified bronchus or lung. On 12/12/22 at 4:17 PM, an interview with resident 16 was conducted. Resident 16…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-15 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Minimum Data Set (MDS) assessment did not accurately reflect the resident's status. Specifically, for 2 out of 20 sampled residents, a resident was incorrectly coded as not having a Traumatic Brain Injury (TBI) and a resident was incorrectly coded as being discharged to the hospital. Resident identifiers: 15 and 26 Findings included: 1. Resident 15 was admitted to the facility on [DATE] with diagnoses which include displaced trimalleolar fracture of left lower leg, localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, essential hypertension, personal history of traumatic brain injury, difficulty in walking, other psychoactive substance abuse, major depressive disorder, mood disorder, and personal history of other venous thrombosis and embolism. Resident 15's admission MDS assessment dated [DATE], was marked No for resident 15 having a TBI. On 12/13/22 at 2:43 PM, an interview with the Assistant Director 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.
- Potential for harm · Dcited before2022-12-15 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, for 2 out of 20 sampled residents, a resident's care plan was left blank in multiple sections and a resident's wound care plan was not updated. Resident identifiers: 16 and 80. Findings include: 1. Resident 16 was admitted to the facility on [DATE] with diagnoses which include acute osteomyelitis (left ankle and foot), chronic obstructive pulmonary disease, dementia, major depressive disorder, schizoaffective disorder, post-traumatic stress disorder, generalized anxiety disorder, cellulitis of left lower limb, peripheral vascular disease, chronic systolic heart failure, adult failure to thrive, muscle weakness, essential hypertension, and malignant neoplasm of unspecified part of unspecified bronchus or lung. On 12/12/22 at 4:17 PM, an interview with resident 16 was conducted. Resident 16 stated that he was upset because he had been a resident at the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-15 · tag F0742 — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
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 residents who displayed or were diagnosed with a mental disorder or psychosocial adjustment difficult, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Specifically, for 1 out of 20 sampled residents, a resident with a diagnoses of post-traumatic stress disorder and major depressive disorder who expressed adjustment difficulties was not offered behavioral health services. Resident identifier: 16 Findings included: Resident 16 was admitted to the facility on [DATE] with diagnoses which include acute osteomyelitis (left ankle and foot), chronic obstructive pulmonary disease, dementia, major depressive disorder, schizoaffective disorder, post-traumatic stress disorder, generalized anxiety disorder, cellulitis of left lower limb, peripheral vascular disease, chronic systolic heart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-15 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 2 out of 20 sampled residents, a resident's diuretic medication used to treat high blood pressure was not monitored according to the physician's ordered parameters. In addition, a resident's angiotensin-converting enzyme medication to treat high blood pressure was not monitored according to the physician's ordered parameters. Resident identifiers: 2 and 84. Findings included: 1. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, cerebral palsy, lymphedema, heart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-12-15 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents who used psychotropic drugs received gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. A GDR must be attempted in two separate quarters, with at least one month between attempts, within the first year in which an individual was admitted on a psychotropic medication or after the facility had initiated such medication, and then annually. Specifically, for 1 out of 20 sampled residents, a resident taking a psychotropic medication that was initiated on 3/30/22, had not received a GDR and the medication was not clinically contraindicated. Resident identifier: 10. Findings included: Resident 10 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side, senile degeneration of brain, dementia, major depressive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-15 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents were free of significant medication errors. Specifically, for 1 out of 20 sampled residents, a resident returning from the hospital missed two doses of a seizure medication that was prescribed by the physician at the hospital. Resident identifier: 15 Findings included: Resident 15 was admitted to the facility on [DATE] with diagnoses which include displaced trimalleolar fracture of left lower leg, localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, essential hypertension, personal history of traumatic brain injury, difficulty in walking, other psychoactive substance abuse, major depressive disorder, mood disorder, and personal history of other venous thrombosis and embolism. Resident 15's medical record was reviewed. A progress note dated 12/13/22 at 11:50 AM, stated, Resident having a seizure that lasts 2 minutes, came to and was A&O [alert and oriented] x 4 [oriented…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-15 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not obtain routine dental services to meet the needs of the resident. Specifically, for 1 out of 20 sampled residents, a resident with missing teeth, gum swelling, reported pain, and had a recommendation from the Speech-Language Pathologist (SLP) was not provided dental services for six months. In addition, the resident had not been scheduled for the extractions and the last dental visit was in November 2022. Resident identifier: 12. Findings included: Resident 12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, encounter for surgical aftercare following surgery on the genitourinary system, hydronephrosis with ureteral stricture, calculus of kidney, type 2 diabetes mellitus, sepsis due to Escherichia Coli, atrial fibrillation, hypertension, acute kidney failure, pain, and anxiety disorder. On 12/12/22 at 3:25 PM, an observation was conducted of resident 12's teeth. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-15 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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, and distribute food in accordance with professional standards for food services safety. Specifically, a staff member was observed not sanitizing or changing gloves while distributing food in the dining room. On 12/12/22 at 12:00 PM, the lunch dining service in the main dining room was observed. a. At 12:05 PM, the Dietary Aide (DA) was observed to serve a resident in the main dining area their lunch tray. The DA was observed to have disposable medical gloves on. The DA was observed to enter the kitchen after serving a resident, adjusted her surgical mask, did not change the gloves or sanitize her hands. b. At 12:10 PM, the DA was observed to serve a resident in the main dining area their lunch tray. The DA was observed to have disposable medical gloves on. The DA removed the covering on the fruit cup, scratched her face, and returned to the kitchen to get the resident a juice drink. The DA was observed to return to the kitchen and did not change the gloves or sanitize her hands. The DA…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2021-05-20 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility did not employ a clinically qualified full-time dietitian or other clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility did not employ a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. The Certified Dietary Manager was also working as the maintenance supervisor and was not working full time in the kitchen, and the kitchen supervisor (KS) was not certified. Findings include: On 5/18/21 at 9:22 AM, the kitchen supervisor (KS) was asked to see the certifications for the kitchen staff. The DM's certificate was issued on 10/13/19. A certificate of membership with the Association of Nutrition and Food Service Professionals (ANFP) was also presented. The KS stated that she completed her food handlers permit on 4/28/21, but had to yet receive her card. The KS had a copy of her food handler's permit to view on her phone. Food handler permits…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-20 · tag F0561 — failed to honor residents' choices — isolatedHonor 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 record review and interview it was determined for 1 of 19 sample residents, that the resident was not able to make choices about aspects of their life in the facility, that were significant to the resident. Specifically, a resident was showered during the night shift and was not asked about her preference to shower during the day. Resident identifier: 23. Findings include: Resident 23 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, weakness and tremor. On 5/20/21 at 6:50 AM, resident 23 was observed to have recently braided hair. Resident 23 was interviewed and stated that she needed a nap after her shower early that morning. Resident 23 stated that she tried to remain positive and did not want to complain but she did not want to shower in the middle of the night. Resident 23 stated that she liked to go to bed before 9:00 PM and wanted to shower before going to bed. Resident 23 stated that showering at 4:00 AM was better than not getting a shower, but she did not want…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-05-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for 1 of 19 sample residents, it was determined that the facility did not ensure that the resident's environment remained as free of accident hazards as possible. It was also determined that each resident did not receive adequate supervision and assistance devices to prevent accidents. Specifically, facility staff did not ensure the safety of residents transfers, and neglected to use safety devices to prevent falls. Resident identifier: 11. Findings include: Resident 11 was admitted on [DATE] with diagnoses which included metabolic encephalopathy, muscle weakness, atrial fibrillation, polymyalgia rheumatica, chronic kidney disease, protein malnutrition, transient ischemic attack (TIA), altered mental status, lymphedema, and dementia. On 5/18/21 at approximately 10:20 AM, resident 11 was observed to have a bandage on her left hand. Resident 11 was interviewed and stated that she hurt her hand somehow, but was unsure what happened. On 5/18/21 at approximately…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-05-20 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined for 2 of 19 sample residents, that 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, a licensed practical nurse (LPN) was observed not properly cleaning equipment and a medication administration device according to policy and best practices. It was also observed that the LPN did not follow infection control procedures in medication administration. Resident identifiers: 9 and 16. Findings include: Resident 9 was admitted to the facility on [DATE] with diagnoses which included chronic diastolic heart failure, type 2 diabetes, depression, diabetic chronic kidney disease, obesity, hypercholesteremia, atrophy of thyroid, autoimmune anemia, muscle weakness, hypertension, dependence on supplemental oxygen and hypoxemia. Resident 16 was admitted to the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$6,351 in federal fines across 1 penalty.
- $6,351 — penalty dated 2023-09-05
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 1.9 | +0.1 vs chain |
| Health inspection | 2 of 5 | 1.7 | +0.3 vs chain |
| Staffing | 2 of 5 | 2.1 | -0.1 vs chain |
| Quality measures | 3 of 5 | 4.1 | -1.1 vs chain |
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 / manager | Type | Role | Since |
|---|---|---|---|
| BEAVER VALLEY HOSPITAL | Organization | INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF | since 09/18/1999 |
| LANGFORD, SCOTT | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER | since 09/18/2018 |
| MCSPADDEN, DARIN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2023 |
| CASCADES HEALTHCARE LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2023 |
| FULLMER, CHAD | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2023 |
| POTTER, STERLING | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/18/2018 |
| WHITE, ASHLEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/29/2024 |
CMS files one row per role, so the 16 rows in the source record cover these 7 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.
This home reported $166K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in UT
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Utah Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 465102. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-05-18, 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.