Monument Healthcare Cottonwood Creek

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.

Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 22% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 27% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

Staffing

How full it usually is: this home is certified for 77 beds and averages 65.4 residents a day — about 85% occupied, or roughly 12 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.90 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 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 3.13 hrs/resident/day on weekends vs 3.67 on weekdays — 15% thinner on weekends. RN hours go from 1.01 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

1 administrator has left in the past year.

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

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

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

28 citations, most serious first. The 13 most serious are shown; the remaining 15 are one tap away and print in full.

• Actual harm · Gcited before2024-04-04 · 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 the facility did not, for 2 of 26 sampled residents, ensure that the environment remained as free of accident hazards as possible, and that each resident received adequate supervision and assistance device to prevent accident. Resident identifiers: 35 and 56. Findings include: 1. Resident 56 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction due to thrombosis, type 2 diabetes mellitus, squamous cell carcinoma, protein-calorie malnutrition, atrial fibrillation, need for assistance with personal care, history of falling, mood disorder, pressure ulcer of sacral region, dementia, generalized edema, anemia, hypertension, hyperlipidemia, and renal osteodystrophy. On 4/1/24 at 9:18 AM an observation of resident 56 was made. Resident 56 was sitting in a wheelchair close to the nurses' station. Resident 56 was observed to have a bandage on her head dated 4/1. Resident 56 was unable to explain why she had a bandage on her head. Resident…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2022-05-05 · 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, the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 3 out of 26 sampled residents, residents that had multiple falls with injuries were not provided interventions or adequate supervision to prevent falls from occurring. A resident had a fall that resulted in a left hip fracture and the resident was hospitalized . In addition, a resident had a fall resulting in a hematoma to the forehead. Resident identifiers: 32, 48, and 53. Findings included: 1. Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, psychosis not due to a substance or known physiological condition, dementia, need for assistance with personal care, muscle weakness, unsteadiness on feet, dysphagia, major depressive disorder, presence of…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2022-05-05 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  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 and record review, it was determined, the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, for 1 out of 26 sampled residents, a resident who had experienced a significant weight loss did not have interventions put in place to prevent further significant weight loss. Resident identifier: 53. Findings included: Resident 53 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but not limited to, Alzheimer's disease, muscle weakness, cognitive communication deficit, difficulty in walking, mood disorder due to known physiological condition, major depressive disorder, spondylosis, and chronic pain. Resident 53's medical record was reviewed on 5/5/22. A care plan focus initiated on 5/2/22, documented [Name of resident 53 removed] has nutritional problem or potential nutritional problem r/t (related to) dx (diagnosis)…

  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 · E2024-04-04 · 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, it was determined that the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, soiled ceiling tiles and dusty air vents were observed throughout the facility, the west hall was found to have a urine-like odor, and the facility environment was in disrepair. Findings include: 1. On 4/1/24 at 9:49 AM and 4/2/24 at 10:56 AM, a strong smell of urine was observed throughout the west hall. The odor could not be pinpointed to a specific room or resident. On 4/2/24 at 12:03 PM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated she did notice a smell in the west hall and that the whole west hall had a smell. 2. On 4/3/24 at 12:35 PM, a strong smell of urine was observed throughout the west hall. The odor could not be pinpointed to a specific room or resident. 3. On 4/4/24 at 10:39 AM, a strong smell of urine was observed in the west hall, starting near room [ROOM NUMBER] down to the end of the hall near the nursing…

  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 · E2024-04-04 · tag F0609 — failed to report abuse allegations — pattern
  Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined that for 6 of 26 sampled residents, that the facility did not ensure that all allegations of abuse or neglect were reported to the State Survey Agency (SSA). In addition, the facility did not ensure the results of all investigations of alleged abuse and neglect were reported to the necessary officials, including the SSA, within 5 working days. Due to the facility's identification of missed reporting of reportable allegations and their subsequent implementation of corrective measures, as well as the facility's current compliance in this regulatory area, this deficiency was determined to be past noncompliance. The facility achieved compliance on 3/15/2024. Resident identifiers: 23, 28, 35, 49, 51, 56 Corrective Action On 3/15/2024, the Administrator and DON (Director of Nursing) received training and education on company wide risk management processes to ensure Trigger Events are reported to the Administrator and/or DON. Per the education, 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.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · D2024-04-04 · 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 interviews and record review, it was determined for 2 out of 26 sampled residents, the facility did not ensure that each resident was free from abuse. Specifically, a staff located a female resident standing in front of a male resident, in the male resident's room. The male resident was seated in a wheelchair and had a hand up the shirt of the female resident, touching the female resident's breast. Both residents have significant cognitive impairment. Due to the facility's identification of abuse, subsequent corrective measures, and the facility's current compliance in this regulatory area, the deficiency was determined to be past noncompliance and the facility achieved compliance on 3/25/2024. Resident identifiers: 21 and 51 Corrective Action Action taken to ensure residents are free from abuse following incident involving sexual contact between two residents with significant cognitive impairment on 3/18/24; resident 51 and resident 21: • Residents were immediately separated and redirected. • Resident…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · D2024-04-04 · 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 observation, interview, and record review it was determined, for 1 of 26 sampled residents, that the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming. Specifically, a resident with severely impaired cognitive skills had long fingernails with brown substance under the fingernails. Resident identifier: 28. Findings include: 1. Resident 28 was admitted to the facility on [DATE] with diagnoses which included congestive heart failure, chronic obstructive pulmonary disease, dementia, hypertension, chronic kidney disease, polyosteoarthritis, major depressive disorder, and anxiety disorder. On 4/1/24 at 9:51 AM, an observation of resident 28 was made of him standing at the nurse's station in the west hall, his nails were long with a brown substance observed under all of his nails. Resident 28's medical record was reviewed from 4/1/24 through 4/4/24. The MDS (Minimum Data Set) for Cognitive Patterns dated…

  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 · D2024-04-04 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
  Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined, for 1 of 26 sampled residents, that the facility failed to ensure PRN (as needed) orders for psychotropic drugs were limited to 14 days, unless the attending physician or prescribing practitioner believes that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. Specifically, a PRN order for Ativan was ordered for more than 21 days. Resident identifier: 16. Findings include: 1. Resident 16 was admitted to the facility on [DATE] with diagnoses which included encounter for palliative care, dysphagia, major depressive disorder, Alzheimer's disease, chronic kidney disease, anxiety disorder, dementia, hypertension, and type 2 diabetes mellitus. Resident 16's medical record was reviewed from 4/1/24 through 4/4/24. A BIMS (Brief Interview for Mental Status) V3 dated 10/19/23 at 7:08 PM indicated that Cognitive Skills for Daily…

  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 · E2022-05-05 · tag F0550 — failed to protect resident dignity and rights — pattern
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview, it was determined, the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life. Specifically, staff members were observed standing over residents while the residents were provided with meal consumption assistance. In addition, on one occasion a resident was observed to be seated with other residents who were consuming their meal, while the resident was not provided with eating assistance timely. Findings included: On 5/2/22 at 12:06 PM, a resident, who required total assistance with meal consumption, was observed seated in the communal main dining room at a table next to their covered meal. Two other residents were also seated at the table with this resident. The other two residents were provided with their meal and began to consume their lunch while the resident who required total assistance with meals remained unable to consume their lunch. The resident waited from 12:06 PM until 12:28 PM, when the Social…

  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 before2022-05-05 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined, the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 7 out of 26 sampled residents, the facility did not ensure implementation of a resident's care plan interventions regarding limited range of motion and contractures; for three residents, the facility did not update and implement interventions for fall prevention; and, for three residents, the facility was unable to demonstrate development and implementation of dementia related care plans. Resident identifiers: 3, 15, 16, 32, 45, 48, and 53. Findings included: 1. A resident with a care plan for contractures to their bilateral upper extremities and hands did not have care plan interventions implemented. Resident…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2022-05-05 · tag F0744 — failed to care for residents with dementia — pattern
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
  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 ensure residents who displayed or were diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Specifically, for 3 out of 26 sampled residents, the facility was unable to demonstrate development and implementation of interventions for managing residents' dementia with behavioral disturbances. Resident identifiers: 3, 16, and 45. Findings included: 1. Resident 3 was admitted to the facility on [DATE] with medical diagnoses that included, but were not limited to, dementia with behavioral disturbances, wernicke's encephalopathy, anxiety disorder due to known physiological condition, pseudobulbar affect, muscle weakness, type 2 diabetes mellitus, and age-related osteoporosis. Observations were made of resident 3, while on the East wing unit. The following observations were noted; On 5/2/22 at 9:40 AM, resident…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2022-05-05 · 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 and record review, it was determined, the facility did not ensure the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance with F689 and F880 which were cited within the facility's 2018 and 2019 recertification survey. Also, the facility was found to be in non-compliance with F656 and F744 which were cited within the facility's 2019 recertification survey. Findings included: An annual recertification survey was completed on 9/19/18. During the survey deficiencies F580, F609, F622, F679, F684, F689, F697, F712, F756, F757, F758, F760, F773, F842, and F880 were cited. An annual recertification survey was completed on 12/5/19. During the survey deficiencies F604, F656, F676, F684, F689, F725, F744, F761, and F880 were cited. An abbreviated, complaint survey was completed on 12/14/20. During the survey deficiency F580, F600, F607, F609, F610, F744, F835, F865, and F943 were cited. 1. Based on observation,…

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

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2022-05-05 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, observations were made of staff administering medications without following hand hygiene protocols, staff were observed to utilize communal vital signs equipment without sanitizing the equipment between resident usage, and residents were observed to consume food items off of other residents dirty meal trays and other residents were observed to consume food from the facility trash cans. Resident identifiers: 10, 16, 25, 33, 35, 40, 45, and 48. Findings included: 1. On 5/4/22, observations were made of Registered Nurse (RN) 1 not sanitizing their hands between medication administrations to different residents. On 5/4/22 at 7:32 AM, an observation was made of RN 1 preparing resident medications. RN 1 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.

  Infection Control 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

$17,940 in federal fines across 1 penalty.

• $17,940 — penalty dated 2024-04-04

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 MONUMENT HEALTH GROUP — 11 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 33 rows in the source record cover these 17 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.

5 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 93% 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 $3.8M paid to related parties — landlords or management companies under common ownership — equal to about 56% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in UT