Provo Rehabilitation and Nursing

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.

50.7% 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 48 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.70 therapist hours per resident per day in 2026Q1 — more than 92% 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 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.

Staffing

How full it usually is: this home is certified for 220 beds and averages 129.5 residents a day — about 59% occupied, or roughly 90 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 3.88 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.87 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.15 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.44 hrs/resident/day on weekends vs 4.06 on weekdays — 15% thinner on weekends. RN hours go from 0.97 to 0.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%.

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

Inspection trend

Deficiencies are 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.

75 citations, most serious first. The 37 most serious are shown; the remaining 38 are one tap away and print in full.

• Immediate jeopardy · Jcited before2026-03-16 · 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 interview and record review, it was determined that the facility failed to provide respiratory care and tracheostomy care to residents who required these services. Specifically, for 3 out of 9 sampled residents, staff did not follow physician orders for changing tracheostomies; staff were not obtaining needed consultations with outside providers; staff were not accurately documenting the resident condition prior to the tracheostomy change; staff did not initiate a hospital transfer for a resident with concerns about the integrity of the tracheostomy. Additionally, staff interviews revealed knowledge of faulty equipment with a resident experiencing a broken flange which caused a dislodged tracheostomy, and subsequently going into cardiac arrest and dying. Finally, a resident found to have his BiPap (Bilevel Positive Airway Pressure) displaced was found to be unresponsive and CPR (cardiopulmonary resuscitation) was begun and the resident was unable to be resuscitated and passed away. The findings for…

  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
• Actual harm · Gcited before2026-03-16 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  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 interview and record review it was determined that the facility did not ensure that the resident was free from neglect. Specifically, for 2 out of 9 sampled residents, the facility did not provide the resident with access to an outside provider appointment for the treatment and care of their tracheostomy tube and verbal orders for the tracheostomy change were not followed. In addition, a comatose resident in a vegetative state experienced a broken flange which caused a dislodged tracheostomy, and the resident subsequently went into cardiac arrest and died. This resulted in a finding of harm for 2 residents. Resident identifiers: 1 and 9. Findings included:1. Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage. Resident 1's medical records were reviewed. Resident 1's physician orders revealed the following: a. Change Tracheostomy tube Q (every) 45 days and PRN (as needed) every day shift every…

  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 · Gcited before2026-03-16 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not ensure that all alleged violations involving injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, if the events resulted in serious bodily injury to the administrator, State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, for 1 out of 9 sampled residents, the SSA and APS were not notified when a resident's tracheostomy flange broke, resulting in a dislodged tracheostomy tube. The resident subsequently went into cardiac arrest and died. This will be cited at a harm level. Resident identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas. A review of resident 9's medical record revealed the following notes:a. On [DATE] at 11:00 PM, a late entry respiratory therapy note documented, At approximately 2100 [9:00…

  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 · Gcited before2026-03-16 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility in response to an allegation of abuse, neglect, or mistreatment did not have evidence that the alleged violation was thoroughly investigated. Specifically, for 1 out of 9 sampled residents, an investigation into the cause of a broken tracheostomy flange in a comatose resident that was dependent on a ventilator was not investigated. This will be cited at a harm level. Resident identifier: 9.Findings included: Resident 9 was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas. A review of resident 9's medical record revealed that on [DATE] at 9:00 PM, respiratory staff entered resident 9's room and found the tracheostomy flange broken, the tracheostomy tube was dislodged, and approximately 1.5 inches out of position, shifted to the right and not midline. Respiratory therapy staff notified nursing and called for a second respiratory…

  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 · G2026-03-16 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that the facility did not ensure that the services provided by the facility met professional standards of practice. Specifically, for 1 out of 9 sampled residents, the facility Respiratory Therapist Director did not ensure that a Verbal Order (VO) was entered into the resident's medical record which resulted in the respiratory staff providing a treatment that deviated from the prescribed order. This will be cited at a harm level. Resident identifier: 1.Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage.Resident 1's medical records were reviewed.Resident 1's physician orders revealed the following:a. Change Tracheostomy tube Q (every) 45 days and PRN (as needed) every day shift every 30 day(s). The order was initiated on [DATE] and discontinued on [DATE]. The same order was initiated again on [DATE] and discontinued on [DATE].…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2026-03-16 · tag F0840 — isolated
  Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that the facility did not ensure that the resident was provided access to an outside provider when the qualified professional person was not employed by the facility, and the facility assumed responsibility for obtaining those services in a timely manner. Specifically, for 1 out 9 sampled residents, the facility did not obtain an appointment with an Ear, Nose, and Throat (ENT) provider for the evaluation of a resident's tracheostomy and tracheal stenosis as ordered. This resulted in a finding of harm for resident 1. Resident identifier:1.Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage.Resident 1's medical records were reviewed.Resident 1's physician orders revealed the following:On 12/3/25, resident 1 had an order initiated for an Ear, Nose, and Throat (ENT) referral related to stenosis and tracheostomy status.On 9/25/25,…

  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 · G2026-03-16 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolated
  Have a plan that describes the process for conducting QAPI and QAA activities.
  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 demonstrate identification, reporting, investigation, analysis and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective action. Specifically, the facility did not identify or investigate in their Quality Assurance Performance Improvement (QAPI) three respiratory-related resident deaths. This will be cited at a harm level. Resident identifiers: 1, 5, and 9.Findings included:1. There was noncompliance identified at an IJ (Immediate Jeopardy) level for residents who were on ventilators and had a tracheostomy changed by respiratory staff when they were not supposed to and another resident's tracheostomy broke. Both of these residents went into cardiac arrest and subsequently died. Resident identifiers: 1 and 9. [Cross refer to F695] 2. Based on interview and record review it was determined that the facility did not ensure that the resident was free from neglect.…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2026-03-16 · tag F0908 — failed to keep essential equipment working — isolated
  Keep all essential equipment working safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined that the facility did not maintain all mechanical, electrical, and patient care equipment in a safe and operating condition. Specifically, a ventilator did not alarm when a resident's tracheostomy tube's flange broke and dislodged and the resident went into cardiac arrest and died. This will be cited at a harm level. Resident identifier: 9. Resident 9 was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas. A review of resident 9's medical record revealed that on [DATE] at 9:00 PM, respiratory staff entered resident 9's room and found the tracheostomy flange broken, the tracheostomy tube was dislodged, and approximately 1.5 inches out of position, shifted to the right and not midline. Respiratory therapy staff notified nursing and called for a second respiratory therapist to assist with the tracheostomy change. During suctioning,…

  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.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-10-21 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  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, the facility did not ensure that residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation. Specifically, for 7 out of 69 sampled residents, residents were having consensual relationships per their families consent and the residents were not assessed and did not have the capacity to consent and residents were being sexually abused by other residents. Resident identifiers: 50, 70, 208, 209, 310, 311, and 409. Findings included: 1. Resident 70 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic kidney disease stage 2, dementia, essential hypertension, mild protein-calorie malnutrition, dysphonia, history of falling, cognitive communication deficit, major depressive disorder, and fall on same level. Resident 70's medical record was reviewed from 10/7/24 through 10/21/24. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 70 had a Brief…

  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 · Hcited before2023-01-30 · 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 interview, record review, and observation the facility did not ensure that 7 of 54 sample residents were free of neglect. Specifically, residents were not assisted with activities of daily living, had untreated pain, experienced weight loss, experienced falls with injuries, and obtained wounds. The findings for all the residents listed in this deficiency were cited at a harm level. Resident identifiers: 22, 27, 33, 47, 146, 244, and 298. Findings include: HARM ASSISTANCE WITH TOILETING 1. Resident 27 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia, Parkinson's disease, neurocognitive disorder with Lewy Bodies, neuropathy, and insomnia. Resident 27's medical record was reviewed on 1/23/23. Resident 27's quarterly Minimum Data Set (MDS) assessment dated [DATE] was reviewed. The MDS indicated that resident 27 was severely cognitively impaired. The MDS indicated that resident 27 required extensive assistance of two people for bed mobility, transferring, dressing, 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
• Actual harm · H2023-01-30 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility did not ensure that 3 of 54 sample residents maintained acceptable parameters of nutritional status. Specifically, residents with weight loss did not receive timely and appropriate interventions. This will be cited at a harm level for all three residents. Resident identifiers: 33, 47, and 244. Findings include: HARM 1. Resident 33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, anxiety disorder, osteoporosis, pseudobulbar affect, major depressive disorder, and hypertension. Resident 33's medical record was reviewed on 1/23/23. Resident 33's weights were recorded as follows: a. 7/5/22 - 179.2 pounds (lbs) b. 1/3/23 - 169.4 lbs The weight loss above is a 5.5 percent weight loss in six months. No other weights were recorded for resident 33 between 7/5/22 and 1/3/23. In addition, no weights were recorded after…

  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
• Actual harm · Hcited before2023-01-30 · tag F0835 — failed to run the facility competently — pattern
  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, record review, and observation, the facility failed to be 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, residents experienced neglect, did not receive assistance with activities of daily living, experienced pain without timely intervention, developed wounds, experienced falls with injuries, and experienced weight loss without timely intervention. This resulted in seven deficiencies cited at a harm level. In addition, multiple deficiencies that were cited on the previous recertification survey and complaint surveys were re-cited on the current survey. Resident identifiers: 22, 27, 33, 41, 47, 60, 146, 244, 295, 298, and 349. Findings include: 1. Based on interview, record review, and observation the facility did not ensure that 7 of 54 sample residents were free of neglect. Specifically, residents were not assisted with activities of daily living, had untreated pain, experienced weight loss, and…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Actual harm · Hcited before2023-01-30 · tag F0867 — failed to act on quality-improvement findings — pattern
  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, record review, and observation, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies; and regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. Specifically, residents experienced neglect, did not receive assistance with activities of daily living, experienced pain without timely intervention, developed wounds, experienced falls with injuries, and experienced weight loss without timely intervention. This resulted in seven deficiencies cited at a harm level. In addition, multiple deficiencies that were cited on the previous recertification survey and complaint surveys were re-cited on the current survey. Resident identifiers: 22, 27, 33, 41, 47, 60, 146, 244, 295, 298, and 349. Findings include: 1. Based on interview, record review, and observation the facility did not ensure that 7 of 54 sample residents were free of neglect. Specifically, residents were not assisted with…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-01-30 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
  Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 54 sampled residents, that the facility did not provide the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs). Specifically, a resident did not receive help with feeding assistance and cueing. The deficient practice identified was found to have occurred at a harm level. Resident Identifier: 244. Findings include: Resident 244 was admitted to the facility on [DATE] with diagnoses that included but not limited to gastro esophageal reflux disease, muscle weakness, major depressive disorder, anxiety disorder, and insomnia. Resident 244's medical record was reviewed on 1/24/23. An annual Minimum Data Set (MDS) assessment dated [DATE], documented that resident 244 required supervision assistance with one person. In addition, a quarterly MDS assessment dated [DATE] documented that resident 244 had a Brief Interview for Mental Status (BIMS) score of 15. A Plan of Care problem…

  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
• Actual harm · Gcited before2023-01-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility did not ensure that 4 of 54 sample residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, residents were not assisted with toileting or bathing as needed. This resulted in a finding of harm for one resident. Resident identifiers: 27, 60, 295 and 349. Findings include: HARM 1. Resident 27 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia, Parkinson's disease, neurocognitive disorder with Lewy Bodies, neuropathy, and insomnia. Resident 27's medical record was reviewed on 1/23/23. Resident 27's quarterly Minimum Data Set (MDS) assessment dated [DATE] was reviewed. The MDS indicated that resident 27 was severely cognitively impaired. The MDS indicated that resident 27 required extensive assistance of two people for bed mobility, transferring, dressing, and toilet use. The MDS indicated that…

  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
• Actual harm · G2023-01-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined that the facility did not ensure, for 1 of 54 sample residents, that all residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices. Specifically, one resident developed a penile wound and did not promptly receive appropriate wound care follow up and no investigation was done on the cause of the wound. The deficient practice identified was found to have occurred at a harm level. Resident Identifier: 244. Findings include: Resident 244 was admitted to the facility on [DATE] with diagnoses that included but not limited to gastro esophageal reflux disease, muscle weakness, major depressive disorder, anxiety disorder, and insomnia. Resident 244's medical record was reviewed on 1/24/23. A Plan of Care problem with an effective date of 1/4/17 documented that resident 244 required extensive assist for bed mobility, transfers, eating, toilet use and personal…

  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
• Actual harm · Gcited before2023-01-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, for 3 of 54 sampled residents, that the facility did not ensure that the residents' environment remained as free of accident hazards as is possible. Specifically, one resident with a history of falls was left unattended and subsequently fell out of bed, receiving an eye laceration. The deficient practice for this resident was cited at a harm level. In addition, one resident with a history of falls was observed to not have interventions in place, and one resident was left unattended at the side of his bed. Resident identifiers: 27, 41 and 146. Findings include: HARM 1 . Resident 146 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis, polyneuropathy, Parkinson's disease and generalized anxiety disorder. Resident 146's medical record was reviewed on 1/23/23. On 1/6/23 a Fall Committee note indicated that resident 146 had experienced 3 falls where she was found on the floor mat next to her bed. No injuries occurred . already in a low…

  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
• Actual harm · Gcited before2023-01-30 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility did not ensure that pain management was provided to 2 of out 54 residents. Specifically, residents complained of pain but were not provided with pain relief medication in a timely manner. These findings resulted in harm for both residents. Resident identifiers: 22 and 298. Findings include: HARM 1. Resident 22 was admitted to the facility on [DATE] with diagnoses that included degenerative disc disease; dementia; schizoaffective disorder, bipolar type; post-traumatic stress disorder; scoliosis; and hypertension. On 1/23/23 resident 22's medical record was reviewed. A care plan for resident 22 was developed on 3/9/20 with a focus area of Has acute and chronic pain r/t (related to) Chronic Physical Disability, pain in lower back, hip and knees. Goals included: Will voice a level of comfort of (sic) through the review date, Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date, and Will not…

  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
• Actual harm · Hcited before2021-05-28 · 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 7 out of 51 residents, that the facility did not ensure that the residents were free from abuse and neglect. Specifically, a resident was not provided catheter care and required treatment at a local hospital for acute sepsis, a resident sustained a fall resulting in a head laceration due to a one person assist when two people were required, a resident with pressure ulcers (PU) located on the bilateral heels did not have the heels floated as ordered and repositioning did not occur for an observed 3 hour time period, and a resident was not provided incontinence care resulting in moisture associated skin damage (MASD) with an open area and a bloody presentation. These examples of neglect were cited at a harm level. Additionally, a resident reported an allegation of verbal and physical abuse from a licensed nurse with medication administration, a resident reported an allegation of physical abuse from a Certified Nurse Assistant (CNA) during…

  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 · H2021-05-28 · tag F0725 — failed to have enough nursing staff — pattern
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 17 of 51 sampled residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, a resident was not provided catheter care and required treatment at a local hospital for acute sepsis, a resident sustained a fall resulting in a head laceration due to a one person assist when two people were required, a resident with pressure ulcers (PU) was not repositioned for an observed 3 hour time period, a resident was not provided incontinence care resulting in moisture associated skin damage (MASD) with an open area and a bloody presentation. These findings were cited at a harm level for 4 resudents. In addition, a resident reported attempting to hold their bowel movements at night due to safety concerns with 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Actual harm · Hcited before2021-05-28 · tag F0835 — failed to run the facility competently — pattern
  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 observation, record review and interview the facility was not administered in a manner that enabled 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, deficient practices were identified during the survey regarding abuse, neglect, falls, incontinence cares, pain, treatment for psychosocial concerns, and staffing. There were multiple residents who were identified to have outcomes cited at a harm level. Resident identifiers: 1, 8, 17, 37, 56, 61, 82, 84, 85, 88, 94, 96, 98, 99, 101, 102, 103, 105, 108, and 112. Findings include: 1. The facility administration did not ensure that for 7 out of 51 residents, the residents were free from abuse and neglect. Specifically, a resident was not provided catheter care and required treatment at a local hospital for acute sepsis, a resident sustained a fall resulting in a head laceration due to a one person assist when two people were required, a resident with pressure ulcers (PU) located on the bilateral heels did…

  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 · Hcited before2021-05-28 · tag F0867 — failed to act on quality-improvement findings — pattern
  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 observation, record review and interview the facility Quality Assessment and Assurance (QAA) Committee did not develop and implement appropriate plans of action to correct identified quality deficiencies. Specifically, deficient practices were identified during the survey regarding abuse, neglect, falls, incontinence cares, pain, treatment for psychosocial concerns, and staffing. There were multiple residents who were identified to have outcomes cited at a harm level. Resident identifiers: 1, 8, 17, 37, 56, 61, 82, 84, 85, 88, 94, 96, 98, 99, 101, 102, 103, 105, 108, and 112. Findings include: 1. The facility QAA Committee did not ensure that for 7 out of 51 residents, the residents were free from abuse and neglect. Specifically, a resident was not provided catheter care and required treatment at a local hospital for acute sepsis, a resident sustained a fall resulting in a head laceration due to a one person assist when two people were required, a resident with pressure ulcers (PU) located on the bilateral heels did not have the heels floated as ordered and repositioning…

  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 · G2021-05-28 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and observation it was determined, for 1 of 51 sample residents, that the facility did not provide care to prevent unavoidable pressure ulcers, nor did they provide timely treatment and services for the resident's pressure ulcer. Specifically, a resident developed an unstageable pressure sore and was not provided interventions to prevent the pressure sore. In addition, after the pressure sore was developed treatment and services were not provided in a timely manner to heal the pressure sore. This resulted in a finding of harm. Resident identifier: 108. Findings include: Resident 108 was admitted to the facility on [DATE] with diagnoses that included pneumonia, muscle weakness, difficulty in walking, need for assistance with personal care, cognitive communication deficit, heart failure, dementia, urinary tract infection, hyperlipidemia, hypertension, diabetes, and chronic pain. Resident 108's medical record was reviewed on 5/23/21. On 4/29/21, staff completed an Initial admission…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2021-05-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 3 of 51 sample residents, that the facility did not ensure residents received adequate supervision and assistance devices to prevent accidents. Specifically, one resident was assisted with a brief change with only one staff member instead of two, resulting in the resident falling out of bed and sustaining a head laceration. This incident was found to have occurred at a harm level. In addition, a resident sustained a burn after a staff member placed a wet wash cloth from the microwave on the resident. This incident was found to have occurred at a harm level. Another resident was not assessed to determine if he was safe to smoke independently. Resident identifiers: 1, 37, and 103. Findings include: HARM 1. Resident 1 was admitted on [DATE] with diagnoses that included functional quadriplegia, diabetes mellitus, chronic respiratory failure with hypoxia, dysphagia, muscle weakness, , hypertension, difficulty walking, atrial fibrillation, 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2021-05-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record the review, for 6 of 51 sample residents, it was determined that the facility did not ensure that residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, the facility failed to ensure proper care for a resident with a urinary catheter which resulted in the resident being hospitalized . This finding was cited at a harm level. In addition, a resident was not toileted timely, resulting in the resident having skin breakdown. This finding was also cited at a harm level. In addition, residents were not placed on a bowel and bladder training program despite requests and staff assessment of appropriateness Resident identifiers: 37, 82, 84, 99, 102, and 112. Findings include: HARM 1. Resident 84 was admitted to the facility 1/1/21. He has a history of traumatic subdural hemorrhage, nontraumatic subarachnoid hemorrhage, falls, tracheostomy,…

  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
• Actual harm · Gcited before2021-05-28 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record the review, for 3 of 51 sample residents, it was determined that the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident experienced uncontrolled pain from a hip fracture for at least six hours prior to being sent to the hospital. This resulted in a finding of harm. In addition, the nursing staff did not provide oral or topical pain medication to residents who were complaining of pain. Resident identifiers: 17, 53 and 110. Findings include: HARM 1. Resident 110 was admitted on [DATE] with diagnoses which included a history of dementia with behavioral disturbance, displaced interochanteric fracture of right femur, convulsions, anemia, cognitive communication deficit, dysphagia, type 2 diabetes, anxiety disorder, primary hypertension and major depression 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2021-05-28 · tag F0742 — isolated
  Provide 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 observation, interview and record review it was determined, for 1 of 51 sample residents, that the facility did not ensure that a resident who displayed or was diagnosed with mental disorder or psychosocial adjustment difficulty, 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 practical mental and psychosocial well-being. Specifically, a resident that attempted suicide was not provided mental health services. This was found to have occurred at a harm level. Resident identifier: 99. Findings include: Resident 99 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included multiple sclerosis, post-traumatic stress disorder, muscle weakness, anxiety disorder and major depressive disorder. On 5/26/21 at 11:22 AM, an interview was conducted with resident 99. Resident 99 stated that she attempted suicide after an agency Certified Nursing Assistant (CNA)…

  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 · Ecited before2024-10-21 · 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, interview, and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, steam table was soiled, hood vents were dusty, the wall behind the dish machine was soiled, tile missing grout, and a fan had dust build up. Findings included: 1. On 10/7/24 at 10:36 AM, an initial tour of the kitchen was conducted. The following was observed: a. Under the steam table shelf which was above the food, the steam table was observed to be soiled. b. The hood vents were observed to have dust in it. The hood vents were above the stove, tilt stove, and oven. According to a sticker the last time the hood vents were inspected was April 6th, 2024. It revealed that hood vents were due to be cleaned 10/6/24. c. There was a wall behind the dish machine that was soiled with a yellow/brown substance with a hole in the wall. d. There was missing grout in the tile in the dish machine room. 2. On 10/21/24 at 10:32 AM, a follow-up kitchen tour was conducted. The following was observed: a. The…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-10-21 · tag F0609 — failed to report abuse allegations — isolated
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, 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 were reported immediately, but not later than two hours after the allegation was made to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, for 2 out of 69 sampled residents, notification to the SSA and APS was not done when residents with cognitive impairments and without the capacity to consent were found in a resident room and one of the residents was disrobed from the waist down. Resident identifiers: 70 and 208. Findings included: 1. Resident 70 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic kidney disease stage 2, dementia, essential hypertension, mild protein-calorie malnutrition, dysphonia, history of falling, cognitive communication deficit, major depressive disorder, and fall on same level.…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-10-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that each resident received adequate supervision to prevent accidents. Specifically, for 2 out of 69 sampled residents, a resident with cognitive impairment eloped from the facility memory care unit. In addition, a resident with cognitive impairment was moved out of the memory care unit and eloped from the facility. Resident identifiers: 50 and 70. Findings included: 1. Resident 70 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic kidney disease stage 2, dementia, essential hypertension, mild protein-calorie malnutrition, dysphonia, history of falling, cognitive communication deficit, major depressive disorder, and fall on same level. Resident 70's medical record was reviewed from 10/7/24 through 10/21/24. On 3/18/23 at 9:35 AM, an Elopement/Wandering Evaluation documented that resident 70 was a Low Risk. On 3/23/23 at 7:54 AM, a Social Service Summary note documented [Resident 70] is admitted…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-10-21 · 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 a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences. Specifically, for 1 out of 69 sampled residents, a resident that required oxygen (O2) therapy did not have physician's orders indicating the type of oxygen delivery system, when to administer the oxygen, and the equipment settings for the prescribed flow rates. Resident identifier: 103. Findings included: Resident 103 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic encephalopathy, pneumonia, acute posthemorrhagic anemia, hypovolemic shock, and chronic obstructive pulmonary disease. On 10/8/24 at 9:35 AM, an observation was made of Licensed Practical Nurse 5 placing resident 103's O2 tubing and positioning the nasal cannula (NC) on resident 103's face. On 10/10/24 at 10:32 AM, an…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-10-21 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that pain management was provided to residents who required such services. Specifically, for 1 out of 69 sampled residents, a resident that complained about mouth pain for approximately ten months was not provided interventions timely. Resident identifier: 64. Findings included: Resident 64 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, anoxic brain damage, antisocial personality disorder, delusional disorders, dysphagia, anxiety disorder, psychotic disorder with delusions, mood affective disorder, major depressive disorder, mild protein-calorie malnutrition, essential hypertension, and mental disorder. Resident 64's medical record was reviewed on 10/9/24 through 10/21/24. A care plan Focus initiated on 6/7/23 and revised on 9/16/24, documented PAIN [resident 64] has acute/chronic pain r/t [related to] Cervicalgia, Polyneuropathy, GERD [gastroesophageal reflux disease], mouth pain and low back pain.…

  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 · D2024-10-21 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide routine and emergency drugs to its residents. Specifically, for 1 out of 69 residents, a resident that was experiencing pain, agitation, and depression did not have their medications available for administration. Resident identifier: 64. Findings included: Resident 64 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, anoxic brain damage, antisocial personality disorder, delusional disorders, dysphagia, anxiety disorder, psychotic disorder with delusions, mood affective disorder, major depressive disorder, mild protein-calorie malnutrition, essential hypertension, and mental disorder. Resident 64's medical record was reviewed on 10/9/24 through 10/21/24. On 1/18/24 at 4:51 PM, an electronic Medication Administration Record (eMAR) -Medication Administration Note documented Note Text : Zoloft Oral Tablet Give 200 mg [milligrams] by mouth in the evening for depression refill request sent. The January 2024…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-10-21 · tag F0757 — failed to avoid unnecessary drugs — isolated
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 69 sampled residents, a resident administered his own blood pressure medication, diabetes medication, and blood thinner that his family member brought from home. There was no documentation from the nurse regarding the incident, dosage of the medications, and why medications were listed as administered by the nurse. Resident identifier: 160. Findings included: Resident 160 was admitted to the facility on [DATE] and readmitted after surgery on 9/28/24 with diagnoses which included fracture of shaft of right fibula, diabetes mellitus (DM), mild protein…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2023-01-30 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined, the facility did not maintain an infection prevention and control program that was designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, observations were made of staff and outside providers not wearing personal protective equipment (PPE) correctly, the appropriate PPE not being worn in contact and droplet isolation rooms, observations of cross contamination during medication pass and wound care, soiled staff telecommunication equipment being used without being cleaned, and equipment not being cleaned in between resident use. Resident identifiers: 21, 27, 50, 82, 244 and 295, Findings include: PPE 1. On 1/25/23 at approximately 10:00 AM, Licensed Practical Nurse (LPN) 6 was observed to answer a phone call at the nurse's station in the 100 hall. LPN 6 was observed to remove her mask while she was speaking on the phone. 2. On…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2023-01-30 · tag F0583 — failed to protect personal privacy — pattern
  Keep residents' personal and medical records private and confidential.
  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 ensure that the residents' medical records were secure and confidential. Specifically, observations were made of a computer screen and paperwork left unattended and displaying residents' personal information. Findings included: On 1/23/23 at 8:15 AM, a computer on the medication cart in the 500 hallway was observed. The computer was open to a resident's medical record. Staff were observed at the other end of the hallway. On 1/25/23 at 8:38 AM, an interview was conducted with Licensed Practical Nurse (LPN) 5. LPN 5 stated computers should be locked and all resident information should be covered to protect each resident's privacy. On 1/26/23 at 12:15 PM, an observation was made of the medication cart on the 500 hallway. Paperwork with resident information which included resident names, medical diagnoses, isolation precautions and code status was left face up on top of the medication cart. Resident family members were observed in the hallway near the medication cart. Staff were not observed in the hallway.…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2023-01-30 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, the wall behind the head of the bed in rooms 504, 505, 506 and 510 were in disrepair. The base of the intravenous (IV) poles and the front of the night stands in rooms 500, 501, 504, 505, 506, 508, and 510 were covered with layers of dried enteral feeding solution and the night stands had many areas of missing paint on the top, sides and front. Additionally, the wheelchairs throughout the facility were dirty and not cleaned regularly. Resident identifiers: 24, 27, 50, 68, 81, 82, 85, 298, and 349. Findings included: 1. Resident 24 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included heart failure, diabetes mellitus, respiratory failure, dependence on a ventilator, obesity, pain, muscle weakness, and need for assistance with personal care. Resident 50 was originally admitted to…

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

  Resident Rights 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

$73,003 in federal fines across 2 penalties.

• $17,857 — penalty dated 2026-03-16
• $55,146 — penalty dated 2024-10-21

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 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 18 rows in the source record cover these 13 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.

8 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 73% 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 $1.5M 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 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