City Creek Post Acute
165 South 1000 East, Salt Lake City, UT 84102 · For profit - Partnership · 108 certified beds · (801) 322-5521 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2022
- 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
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (21) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- it did not file the payroll staffing data CMS requires — its 1 of 5 staffing rating is the rating CMS assigns for not reporting, not a measure of how many nurses are on the floor
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 11.2% | 11.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.1% | 3.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.5% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.9% | 1.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 29.1% | 16.5% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.4% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 12.5% | 15.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 24.7% | 25.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.2% | 3.9% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.6% | 21.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.8% | 14.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 0.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 91.0% | 91.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 7.2% | 16.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 12.2% | 11.6% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 1.08 | 1.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.21 | 1.43 | 1.80 | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
48.5% 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 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 56.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 30 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.51 therapist hours per resident per day in 2026Q1 — more than 82% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% 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 | 48.5%CMS range 36.1–61.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 5.5–14.8 | 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 | 56.7% | 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 | 63.3% | 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 | 46.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.79 | 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
No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
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.
21 citations, most serious first. The 13 most serious are shown; the remaining 8 are one tap away and print in full.
- Actual harm · Gcited before2026-03-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure each resident received adequate supervision to prevent accidents. Specifically, for 1 out of 43 sampled residents, one resident sustained a third-degree burn to his left wrist from spilling a prepackaged soup prepared and served by facility staff. Resident identifier: 3.It was determined the provider's non-compliance with the requirements of participation had caused harm. The harm was related to the State Operations Manual, Appendix PP, S483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents, F689, at a scope and severity of G. However, based on the facility's corrective actions and a review of its current compliance in this regulatory area, the deficiency was determined to be past noncompliance.The facility developed and implemented a corrective action plan before the survey start date. The facility's corrective action plan, which was developed and implemented by 3/11/26 included the following…
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 · G2022-05-04 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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, for 2 of 23 sample residents, that each resident did not have the right to be free from abuse. Specifically, a resident was threatened by a roommate and there was no investigation to rule out abuse. Resident identifier: 33 and 89. Findings include: Resident 33 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance, major depressive disorder, personal history of transient ischemic attack, diabetes, and cerebral infarction. On 5/2/22 at 9:11 AM, an interview was conducted with resident 33. Resident 33 stated her roommate tried to kill her. Resident 33 stated that her roommate told her that she was going to stab her. Resident 33 stated she was unable to sleep at night. Resident 33 stated that her roommate was not at the facility very long. Resident 33's medical record was reviewed on 5/3/22. An admission Minimum Data Set (MDS) dated [DATE] revealed resident 33 had a Brief Interview of Mental Status (BIMS)…
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 · G2022-05-04 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 23 sample residents, 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 residents' choices. Specifically, a resident was not treated for a urinary tract infection (UTI). Resident identifier: 38. Findings include: Resident 38 was admitted to the facility on [DATE] and with diagnoses which included urinary tract infection, acute respiratory failure, wedge compression fractures, diabetes mellitus, and asthma. Resident 38's medical record was reviewed on 5/4/22. A physician's order dated 4/7/22 revealed Urine Analysis (UA) with reflux culture patient was having urine retention and may perform straight catheter to obtain culture. The urine analysis and culture were not located in resident 38's medical record. The Assistant Director of Nursing (ADON) provided the UA with reflux culture dated 4/7/22. The form was flagged as abnormal.…
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 · E2026-03-30 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, a Bluetooth speaker was stored on a shelf used to store items used in food preparation and a male staff member with a beard was observed to be preparing food without wearing a beardnet. Findings included:On 3/23/26 at 8:02am an initial observation was conducted of the facility kitchen. There was a Bluetooth speaker sitting on a shelf used to store hotel pans used for meal preparation.On 3/25/25 at 11:31am a follow up observation was conducted of the facility kitchen. [NAME] 1 was observed to have a beard. [NAME] 1 was not wearing a beard net while preparing enchiladas that were to be served to residents at lunch. On 3/26/26 at 8:36am, an interview was conducted with the Dietary Manager (DM). The DM stated that she would purchase beard nets for the male staff member that was not wearing a beard net while preparing food. The DM also stated that she would move the bluetooth speaker to an area of the kitchen…
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 before2026-03-30 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 3 out of 43 sampled residents, staff did not wear personal protective equipment (PPE) when residents were on Enhanced Barrier Precautions (EBP) and hand hygiene was not performed during wound care. Resident identifiers: 14, 73, and 74.Findings included:1. Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, encephalopathy. On 3/23/26 at 2:21 PM, EBP signage was observed on the door frame and a PPE cart was observed outside of resident 14's room. A care plan Focus documented [name redacted] has potential for pressure ulcer development r/t [related to] Limited mobility d/t [due to] Parkinson's, Encephalopathy and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-30 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
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 when they transferred or discharged a resident that it was documented in the resident's medical record and that the information contained the contact information of the practitioner responsible for the care of the resident; resident representative information; Advanced Directive information; all special instructions for ongoing care; comprehensive care plan goals; and all other necessary information to ensure a safe and effective transition of care. Specifically, for 1 of 43 sampled residents, the facility did not document in the residents' medical record the information that was given to the receiving provider when the resident was transferred to the hospital. Resident identifier: 9. Findings included: Resident 9 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included calculus of bile duct, urinary tract infection (UTI), pneumonia, type 2 diabetes mellitus, systemic inflammatory response syndrome,…
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 · D2026-03-30 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that when a bed rail was utilized that the resident was assessed for the risk of entrapment from the bed rail prior to installation. Specifically, for 1 out of 43 sampled residents, the facility did not evaluate a resident for entrapment from the bed rail prior to use and the resident reported that her hand was caught in the bar. Resident identifier: 65. Findings included: Resident 65 was admitted to the facility on [DATE] with diagnoses which included secondary malignant neoplasm of the brain, malignant neoplasm of the left breast, disorders of bone density, hemiplegia and hemiparesis following a cerebrovascular accident, seizures, weakness, thyrotoxicosis, adjustment disorder with anxiety, and depressed mood. On 3/23/26 at 11:13 AM, an interview was conducted with resident 65 and their representative. Resident 65 stated that she fell off the bed and her hand was caught in the side bar. Resident 65's representative stated that he…
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 · D2026-03-30 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
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 received food that accommodated the resident allergies, intolerances, and preferences. Specifically, for 1 out of 43 sampled residents, the facility did not provide the resident with the food preferences as outlined on their meal ticket. Resident identifier: 8. Finding included: Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included severe protein-calorie malnutrition, cachexia, hypokalemia, hypotension, acute kidney failure, hypomagnesemia, depression, and pain. On 3/24/26 at 8:12 AM, an interview was conducted with resident 8. Resident 8 stated that he was on hospice for malnutrition and met with the Registered Dietician regularly. Resident 8 stated that the kitchen never followed the instructions for his meals. Resident 8 stated that last night's dinner was a salad and he could not digest any leafy green vegetables. Resident 8 stated that he had to order food out…
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 before2024-01-29 · 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
Based on interview and observation, the facility did not ensure that the resident environment remained as free of accidents as possible. Specifically, the laundry room was left open with no staff present; the laundry room was observed to have various chemicals inside. Findings include: On 1/29/24 at 10:43 AM, an observation was made of the first floor laundry room. The laundry room door was cracked open and no staff were located inside the laundry room. An observation was made of several chemicals located on the clean side of the laundry room which included: 4 containers of Febreeze fabric refresher, 7 containers of Comet disinfecting sanitizing bathroom cleaner, 2 bottles of broad range quaternary sanitizer and 2 containers of disinfecting all purpose spray and glass cleaner. Several of the warning labels located on the containers stated to keep out of reach of children and may be harmful if swallowed. Another observation of the door between the clean and dirty laundry room was made. The door had a sign which read this door must not be propped open. That door was found to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-29 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 37 sampled residents, that the facility failed to ensure that a resident with urinary incontinence, based on the resident's comprehensive assessment received appropriate treatment and services to restore continence to the extent possible. Specifically, a resident who was incontinent of bladder and was assessed to be a likely candidate for a toileting program was not provided treatment and services to achieve as much normal bladder function as possible. Resident identifier: 10. Findings include: Resident 10 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses which included diabetes mellitus type 2, congestive heart failure, chronic kidney disease, respiratory failure with hypoxia, atrial flutter, major depressive disorder, and right leg below the knee amputation. On 1/23/24 at 10:16 AM, an interview was conducted with resident 10. Resident 10 stated she used a brief for bladder incontinence and that she wished she was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-05-04 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to prevent the development and transmission of communicable diseases and infections. Specifically, appropriated signage was not placed outside resident rooms identifying the need for transmission-based precautions (TBP), staff were observed in a patient's isolation room without personal protective equipment (PPE) and unvaccinated COVID-19 newly admitted residents were not put on TBP. In addition, staff did not wear appropriate eye protection (goggles or face shields) when interacting with residents and visitors were observed to enter the facility through a back entrance on the second floor and walk down a hallway past residents prior to performing the COVID-19 screening process. Resident Identifiers: 88, 138 and 193. Findings include: 1. Resident 193 was admitted to the facility 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.
- Potential for harm · E2022-05-04 · tag F0886 — failed to test for COVID-19 as required — patternPerform COVID19 testing on residents and staff.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 5 out of 6 sampled staff, that the facility did not conduct testing based on parameters set forth by the Secretary. Specifically, routine testing of unvaccinated staff members, based on community transmission, was not completed. Findings include: On 5/5/22, the Operations Manager (OM) provided the vaccination status of facility staff. Staff member (SM) 1, SM 2, SM 3, SM 4, SM 5 and SM 6. SM 1, SM 3, SM 4, SM 5, and SM 6 had Religious Objections to the COVID-19 vaccination. SM 2 did not have an exemption. The county transmission rate provided by the facility revealed the following: a. 4/4/22 rate was 3.27% indicating weekly COVID-19 testing, b. 4/11/22 rate was 4.07% indicating weekly COVID-19 testing, c. 4/18/22 rate was 5.36% indicating weekly COVID-19 testing, d. 4/25/22 rate was 6.63% indicating twice weekly COVID-19 testing, e. 5/2/22 rate was 11.28% indicating twice weekly COVID-19 testing. COVID-19 testing was reviewed and SM 1 was tested on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-05-04 · tag F0888 — patternEnsure staff are vaccinated for COVID-19
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, it was determined the facility did not develop and implement policies and procedures to ensure that all staff were fully vaccinated for Coronavirus Disease-2019 (COVID-19). The facility did not ensure that the policies and procedures applied to individuals who provided care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement. Also, the facility did not implement policies and procedures that included, at a minimum, a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who were not fully vaccinated for COVID-19. Specifically, the facility was unaware and did not keep documentation of the vaccination status for their contracted staff. In addition, an unvaccinated staff member was not wearing the appropriate personal protective equipment according to the facility's policy and procedures. Findings include: On 5/4/22 at 3:04 PM, an observation was made of Staff member (SM) 3. SM 3 was observed…
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 8 citations
- Potential for harm · D2022-05-04 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 23 sample resident, the facility did not provide the right for residents to choose medical treatment. Specifically, residents Physicians Orders for Life Sustaining Treatment (POLST) forms were not filled out timely after the residents were admitted to the facility. Resident identifiers: 8 and 30. Findings include: 1. Resident 8 was admitted to the facility on [DATE] with diagnoses which included heart failure, type II diabetes, chronic gastritis, hypertension, fibromyalgia, irritable bowel syndrome, carpel tunnel and hypothyroidism. On [DATE] a review of resident 8's medical record was conducted. Resident 8's POLST was not signed by the resident until [DATE] and signed by a medical provider on [DATE]. This was 84 days after admission. 2. Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included gastro-esophageal reflux disease with esophagitis, peptic ulcer, anemia, chronic…
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 · D2022-05-04 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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
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 two showers in the third floor shower room were in disrepair. Findings included: On 5/2/22 at 10:27 AM, an interview was conducted with resident 19. Resident 19 stated the showers had black stuff in the corners, the Certified Nursing Assistant's (CNA) went in after each person and washed it down after each person showered. On 5/4/22 at 3:07 PM, an observation was made of the shower room on the third floor. The following observations were made: a. Shower A had orange rust stains that ran down the tiled wall to the floor. b. Shower A faucet continuously dripped from the end of the hand held shower nozzle. c. Shower A paint peeled along the top of the shower, where the tile met the pain in two locations. d. Shower A had caulk missing around the base of the shower. e. Shower A had multiple tiles with reminents of adhesive residue on the walls. f. Shower A had fauset base pulled out from wall. g.…
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 · D2022-05-04 · tag F0609 — failed to report abuse allegations — isolatedTimely 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 it was determined, for 4 of 23 sample residents, that in response to an allegation of abuse, neglect, exploitation or mistreatment, the facility did not ensure that all alleged violations were report no later than 2 hours after the allegation was made and the results of all investigations were reported within 5 working days of the incident. Specifically, two resident to resident altercations were not reported within 2 hours to the state survey agency. Resident identifiers: 9, 31, 33 and 89. Findings include: 1. Resident 33 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance, major depressive disorder, personal history of transient ischemic attack, diabetes, and cerebral infarction. On 5/2/22 at 9:11 AM, an interview was conducted with resident 33. Resident 33 stated the roommate tried to kill her. Resident 33 stated that her roommate told her that she was going to stab her. Resident 33 stated she was unable to sleep at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-04 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 of 23 sample residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility did not have evidence that all alleged violations were thoroughly investigated. Specifically, a resident threatened another resident and there was no investigation. Resident identifiers: 33 and 89. Findings include: Resident 33 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance, major depressive disorder, personal history of transient ischemic attack, diabetes, and cerebral infarction. On 5/2/22 at 9:11 AM, an interview was conducted with resident 33. Resident 33 stated the roommate tried to kill her. Resident 33 stated that her roommate told her that she was going to stab her. Resident 33 stated she was unable to sleep at night. Resident 33 stated that her roommate was not at the facility very long. Resident 33's medical record was reviewed on 5/3/22. There were no progress…
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 before2022-05-04 · 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 it was determined, for 1 of 23 sample residents, the facility did not ensure that the residents' environment remained as free of accident hazards as was possible or that each resident received adequate supervision to prevent accidents. Specifically, a resident had access to hazardous chemicals and there was a hallway rug outside of a resident's room which a resident tripped over when using a walker. Resident identifier: 194 Findings include: Resident 194 was admitted to the facility on [DATE] with diagnoses which included left knee derangement of patella, bipolar disorder, current episode manic without psychotic features, borderline personality disorder, muscle weakness and unsteadiness on feet. 1. On 5/2/22 at 12:08 PM, an observation was made of resident 194. Resident 194 was observed to ask house keeping for a broom and dust pan so resident could clean behind the door. House keeper was observed to give resident 194 the supplies requested and proceeded to tell…
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 · D2022-05-04 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility did not label all drugs and biologicals used in the facility in accordance with currently accepted professional principles, and did not include appropriate accessory instructions and the expiration date when applicable. Specifically, insulins were not labeled with an open date and administered to residents. The medication cart was not locked when the nurse was not by it. Resident identifier: 8, 19, and 194. Findings included: 1. Resident 19 was admitted to the facility on [DATE] with diagnoses which included type II diabetes, asthma, macular degeneration, suicidal ideation's, hypertension, major depressive disorder, panic disorder, post traumatic disorder, bipolar disorder and anxiety. On 5/3/22 at 7:10 AM, an observation was made of Registered Nurse (RN) 6. RN 6 was observed to obtain a Humulin 70/30 Kwikpen Insulin pen from the medication cart. The insulin pen did not have an open date written on the label. RN 6 stated, We don't know when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-04 · tag F0770 — failed to provide lab services — isolatedProvide timely, quality laboratory services/tests to meet the needs of residents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 23 sampled residents, the facility did not obtain laboratory (lab) services to meet the needs of the residents. Specifically, a resident had physician's orders to obtain a glycated hemoglobin (A1C), Phosphorous (Phos), Complete Metabolic Panel (CMP), C-reactive protein (CRP), and Pre-Albumin for medical monitoring and the labs were not completed timely as ordered. Resident identifiers: 30. Findings included: Resident 30 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included gastro-esophageal reflux disease with esophagitis, peptic ulcer, anemia, chronic kidney disease stage 5, schizophrenia, chronic obstructive pulmonary disease, and dysphagia. On 5/3/22 resident 30's medical record was reviewed. A Registered Dietitian Note dated 4/15/22 revealed a recommendation of follow up labs of A1C, Phos, CMP, CRP and prealbumin. A Nurse Practitioner/Physician Assistant (NP/PA) Progress note dated 4/18/22…
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 · D2022-05-04 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
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 23 sample residents, that the facility did not promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fell outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. Specifically, a resident's urine culture and sensitivity was not reported to the physician. Resident identifier: 38. Findings include: Resident 38 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection, acute respiratory failure, wedge compression fractures, diabetes mellitus, and asthma. Resident 38's medical record was reviewed on 5/4/22. A physician's order dated 4/7/22 revealed Urine Analysis (UA) with reflux culture patient was having urine retention and may perform straight catheter to obtain culture. The urine analysis and culture were not located 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 1 of 5 | 2.7 | -1.7 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ELLIS, KC | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2016 |
| WORKMAN, DAVID | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/20/2024 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | since 05/01/2016 |
| KEETCH, CHAD | Individual | CORPORATE OFFICER | since 03/01/2011 |
| MOSS, TYLER | Individual | CORPORATE OFFICER | since 05/01/2016 |
| AVENUES HEALTHCARE, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2016 |
| CARETRUST GP LLC | Organization | ADP OF THE SNF | since 09/01/2006 |
| CARETRUST REIT INC | Organization | ADP OF THE SNF | since 09/01/2006 |
| CTR PARTNERSHIP LP | Organization | ADP OF THE SNF | since 08/28/2014 |
| ENSIGN SERVICES INC | Organization | ADP OF THE SNF | since 09/01/2006 |
| TENTH EAST HOLDINGS LLC | Organization | ADP OF THE SNF | since 08/28/2014 |
CMS files one row per role, so the 16 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 76% 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 $794K 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
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 465072. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-30, 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.