Monument Healthcare Taylorsville
6246 South Redwood Road, Salt Lake City, UT 84123 · For profit - Limited Liability company · 120 certified beds · (801) 969-1420 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has citations for mishandling residents’ money or property (F0565, F0567, F0568)
- it has 2 actual-harm citations
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $7,525 in federal fines (most recent 2024-03-12)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
- 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
- about 48% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 3 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
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 improved from 1 to 4 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 | 5.8% | 11.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.3% | 3.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.9% | 1.8% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 1.9% | 16.5% | 6.5% | better 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 | 2.9% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 11.7% | 15.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 7.6% | 25.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.3% | 3.9% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 28.3% | 21.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 1.0% | 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 | 96.4% | 91.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.2% | 16.5% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 11.8% | 11.6% | 12.0% | typical |
‡ 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.
57.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 97 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 57.1% 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 35 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 0.27 therapist hours per resident per day in 2026Q1 — more than 40% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 25% 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.
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 | 57.9%CMS range 48.1–67.0 | 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 | 10.4%CMS range 6.9–14.0 | 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 | 57.1% | 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 | 57.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 60.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.9% | 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 | 95.7% | 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 | 7.2%CMS range 3.8–13.8 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.89 | 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.
25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.
- Actual harm · Gcited before2026-02-03 · 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, the facility failed to ensure that each resident received adequate supervision to prevent accidents. Specifically, for 1 out of 41 sampled residents, one resident sustained a second-degree burn from a heat therapy treatment and will be cited at a harm level. Resident identifier: 76. Findings included:Resident 76 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included anterior cord syndrome at C3 level of cervical spinal cord; completed lesion at C4, C5, and C6 level of cervical spinal cord; cognitive communication deficit; spastic hemiplegia; and paresthesia of skin.On 2/2/26 at 8:31 AM, an interview was conducted with resident 76 who stated he was in the shower last Friday and the hot, hot water burned his arm. Resident 76 was observed to have a wrap on his left forearm and two blisters, approximately the size of a dime, on two of the knuckles on his left hand. Resident 76's medical record was reviewed from 1/26/26 through…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-03-12 · 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 that for 2 of 7 sampled residents, that the facility did not ensure that the resident environment remains as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not ensure that a resident transported to a dialysis appointment was properly secured with a seatbelt, and subsequently sustained fractures of both of his legs. In addition, the facility did not ensure that a resident's call light was within reach and the resident reached for the call light, fell out of bed, and fractured his hip. This will be cited at a HARM. Resident Identifiers: 4, 7. Findings included: 1. Resident 7 was admitted to the facility on [DATE] with diagnosis which included encephalopathy, end stage renal disease, spinal stenosis, weakness, limitation of activities due to disability, need for assistance with personal care, and adult failure to thrive. 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 · E2026-02-03 · tag F0761 — failed to label and store drugs safely — patternEnsure 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
Based on observation and interview, the facility did not ensure that drugs and biologicals were labeled in accordance with accepted professional principles and stored in locked compartments. Specifically, observations were made of resident medications left unlocked and unattended on top of the medication cart, a multidose vial of insulin was available for use past its expiration date, and a multidose vial of tuberculin did not contain an open date for the vial. Resident identifiers: 7 and 70. Findings included:1. On 1/28/26 at 8:25 AM, an observation was made of Licensed Practical Nurse (LPN) 1 during morning medication administration. LPN 1 left a blister pack of simvastatin for resident 70 on the top of the medication cart outside the resident's room. LPN 1 walked away from the medication cart to administer medication without securing the simvastatin in the locked medication cart. An immediate interview was conducted with LPN 1. LPN 1 stated that it was easier to pull all the blister packs out of the cart while dispensing medication and she forgot to put the simvastatin back…
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 · D2026-02-03 · tag F0567 — failed to protect residents' money held by the home — isolatedHonor the resident's right to manage his or her financial affairs.
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 the resident had the right to manage their financial affairs and included the right to know, in advance, what charges the facility imposed against a resident's personal funds. Specifically, for 1 out of 41 sampled residents, a resident was not informed in advance that the facility was going to charge against their personal funds the supplemental insurance premiums. Resident identifier: 54. Findings included:Resident 54 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included Multiple Sclerosis, functional quadriplegia, type 2 diabetes mellitus, epilepsy, major depressive disorder, anxiety disorder, and cognitive communication deficit. On 1/27/26 at 3:28 PM, an interview was conducted with resident 54's Power of Attorney (POA). The POA stated that resident 54 received $42.00 a month from the Social Security Administration. The POA stated that resident 54's current account balance was zero. The POA…
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 · D2026-02-03 · tag F0568 — isolatedProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
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 the financial record was available to the resident through quarterly statements and upon request. Specifically, for 1 out of 41 sampled residents, a resident's quarterly statements were not provided to the resident or their personal representative and Power of Attorney (POA). Resident identifier: 54. Findings included:Resident 54 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included Multiple Sclerosis, functional quadriplegia, type 2 diabetes mellitus, epilepsy, major depressive disorder, anxiety disorder, and cognitive communication deficit. On 1/27/26 at 3:28 PM, an interview was conducted with resident 54's POA. The POA stated that resident 54 received $42.00 a month from the Social Security Administration. The POA stated that resident 54's current account balance was zero. The POA stated that she had asked the Business Office Manager (BOM) for a record of last year's account and had not heard…
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 · D2026-02-03 · tag F0571 — isolatedLimit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
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 charges were not imposed against the personal funds of a resident for any item or service for which payment was made under Medicaid or Medicare. Specifically, for 1 out of 41 sampled residents, a resident's Medicaid funded insurance premiums were deducted from the resident's personal funds account and not from the facility Cost of Care (COC). Resident identifier: 54. Findings included:Resident 54 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included Multiple Sclerosis, functional quadriplegia, type 2 diabetes mellitus, epilepsy, major depressive disorder, anxiety disorder, and cognitive communication deficit. On 1/27/26 at 3:28 PM, an interview was conducted with resident 54's Power of Attorney (POA). The POA stated that resident 54 received $42.00 a month from the Social Security Administration (SSA). The POA stated that resident 54's current account balance was zero. The POA stated that she had…
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 · D2026-02-03 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 inform Medicaid-eligible residents when changes were made to the items and services provided. Specifically, for 1 out of 41 sampled residents, changes were made to the residents Medicaid funded supplemental vision and dental insurance and the facility did not provide notice to the resident of the changes timely. Resident identifier: 54. Findings included:Resident 54 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included Multiple Sclerosis, functional quadriplegia, type 2 diabetes mellitus, epilepsy, major depressive disorder, anxiety disorder, and cognitive communication deficit. On 1/27/26 at 3:28 PM, an interview was conducted with resident 54's Power of Attorney (POA). The POA stated that resident 54 received $42.00 a month from the Social Security Administration. The POA stated that resident 54's current account balance was zero. The POA stated that she had asked the Business Office Manager (BOM) for 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.
- Potential for harm · D2026-02-03 · tag F0627 — isolatedEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
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 must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the health or safety of an individual in the facility is endangered; the licensee ceases to operate the facility; the resident has failed, after reasonable and appropriate notice, to pay for a stay at the facility; the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; or the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. Specifically, for 2 out of 41 sampled residents, two residents were inappropriately discharged from the facility after going on leave of absence. Resident identifiers: 115 and 137. Findings included: 1. Resident 115 was admitted to the facility on [DATE] and discharged on 11/24/25. Resident 115 had diagnoses which included, but were not limited…
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 · D2026-02-03 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide the necessary care and services to ensure that the resident was given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living. Specifically, for 1 out of 41 sampled residents, a resident was not provided assistance with showers per their preferences and as outlined in their shower schedule. Resident identifier: 116. Findings included:Resident 116 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, bacterial meningoencephalitis, nontraumatic intracranial hemorrhage, ataxia, dysphagia, and cognitive communication deficits.On 1/26/26 at 9:08 AM, an interview was conducted with resident 116. Resident 116 stated she only had two showers since admission and would like to receive more. Resident 116's medical record was reviewed on 1/26/26 through 2/3/26. Resident 116's bathing task documented that the resident was scheduled for showers on Wednesday 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 · D2026-02-03 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 41 sampled residents,an assessment of the resident's condition and monitoring for complications before and after dialysis treatments were not completed. Resident identifier: 13. Findings included:Resident 13 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease, automatic cardiac defibrillator, cardiomyopathies, and hypo-osmolality and hyponatremia.Resident 13's medical record was reviewed from 1/26/26 through 2/3/26.A Physician's Order dated 8/25/25, indicated, COMPLETE the Dialysis Post Assessment Form after resident returns from dialysis. Ensure resident returns from dialysis with the Pre-Dialysis Assessment and Communication Form. Review and follow up as indicated. Call Dialysis…
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 · D2026-02-03 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 2 out of 41 sampled residents, a resident receiving medication to prevent infection and a resident receiving medication for diabetes mellitus did not have those medications available from the pharmacy for administration. Resident identifiers: 2 and 49. Findings included:1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus (DM).A physician order dated 1/3/26, documented Dapagliflozin Propanediol Oral Tablet 5 MG [milligrams] (Dapagliflozin Propanediol) Give 1 tablet by mouth one time a day for DM.The January 2026 Medication Administration Record (MAR) was reviewed. Resident 2 had missed seven doses of the medication due to the dapagliflozin propanediol being not available from the pharmacy.2. Resident 49 was admitted to the facility on [DATE] with diagnoses which included, but were not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-03 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was defined as any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences. Specifically, for 1 out of 41 sampled residents, blood pressure medications were administered outside of parameters and professional standards of care. Resident identifier: 13. Findings included:Resident 13 was admitted to the facility on [DATE] with diagnoses which included heart failure, end stage renal disease, automatic cardiac defibrillator, pulmonary hypertension, and ventricular tachycardia.Resident 13's medical record was reviewed from 1/26/26 through 2/3/26.A Physician's Order dated 12/23/25, indicated, Metoprolol Succinate ER [extended release] Oral Tablet Extended Release 24 Hour (Metoprolol Succinate) Give 12.5 mg [milligrams] by mouth one time a day for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2026-02-03 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not provide or obtain outside resources for routine or emergency dental services to meet the needs of the resident. Specifically, for 1 out of 41 sampled residents, a resident that asked to see the dentist for a broken tooth did not have those services arranged. Resident identifier: 49. Findings included:Resident 49 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, diverticulitis of large intestine without perforation or abscess without bleeding.On 1/27/26 at 8:54 AM, an interview was conducted with resident 49. Resident 49 stated she broke her tooth a week ago here at the facility. Resident 49 stated that the pain could be a little stabby. Resident 49 stated the staff had not offered her pain medications and she felt like the staff had forgotten about her. Resident 49 stated the staff told her she would see a dentist but that had not happened.On 1/23/26 at 12:41 PM, a COMMUNICATION: with physician (narrative)…
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 · D2026-02-03 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility did not store food in accordance with professional standards for food service safety. Specifically, the residents personal food fridge had two food containers that were not labeled with a date. Findings included:On 1/28/26 at 9:59 AM, an observation was made of the resident personal food fridge. On the front of the fridge was a sign that indicated, Resident Personal Food Fridge Put residents name & date on ALL items. Items must be covered and will be thrown out after 3 days from the date. Inside the refrigerator there was one large container that had a cloudy, brown, soup-like liquid in it with brown meat-like substance. Another styrofoam container was located in the fridge that contained vegetables. Both containers were not labeled with a resident name or date.A concurrent interview was conducted with Licenced Practical Nurse (LPN) 6. LPN 6 stated the two unlabeled food containers should be thrown away because they were not labeled with a resident name and date.On 2/3/26 at 10:44 AM, an interview was conducted with the Director of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-02-03 · tag F0840 — isolatedEmploy or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the use of outside resources. Specifically, for 1 out of 41 sampled residents, a referral for a urology consultation was not made for a resident. Resident identifier: 70.Findings included:Resident 70 was admitted to the facility on [DATE] with diagnoses which included, but not limited to muscle weakness, need for personal assistance, catheter use, and neurogenic bladder. A physician order dated 11/17/25, documented Refer patient to urology for suprapubic eval [evaluation] r/t [related to] frequent catheter leaking.No referral was made for resident 70 until 1/13/26. On 2/3/26 at 9:26 AM, an interview was conducted with the Director of Nursing (DON) who stated she was unsure why the referral to the urologist for resident 70 had not been made. On 2/3/26 at 9:29 AM, an interview was conducted with the Resident Relations Manager (RRM) who stated there was not an appointment for resident 70 on the calendar. RRM stated nursing makes…
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 · D2024-03-12 · 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, that for 2 of 7 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hour if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Specifically, the facility did not report two instances of potential neglect related to serious bodily injury to the State Survey Agency (SSA). Resident Identifiers: 4,7.…
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 · D2024-03-12 · 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 7 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident with heart failure had hospital discharge orders for daily weights, the order was not implemented at the facility until 6 days after the resident was admitted . Resident Identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included heart failure, peripheral vascular disease, presence of prosthetic heart valve, and tricuspid stenosis. A review or resident 1's hospital discharge paperwork documented a discharge order, Monitor weight and record . Please weigh and record your weight: Daily. Call the provider if you have gained or lost pounds: 7-10. Resident 1's care plan did not include any focus areas involving daily weights. 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.
- Potential for harm · E2023-11-16 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, it was determined that the facility did not consider the views of a resident or family group and act promptly upon the grievances and the recommendations of such groups concerning issues of resident care and life in the facility. Specifically, the facility did not follow up on grievances filed by residents. Findings include: On 11/16/23, the facility grievance long was reviewed for the past year. The following grievances were found with no resolutions: On 1/26/23, a grievance was filed about food at the facility. No resolution or follow up on the grievance was documented in the grievance log. On 2/26/23, a grievance was filed about a resident to staff interaction. No resolution or follow up on the grievance was documented in the grievance log. On 4/27/23, two separate grievances were filed about food at the facility. No resolution or follow up on the grievances was documented in the grievance log. On 5/22/23, a grievance was filed by the resident council about food at the facility. No resolution or follow up on the grievance was documented in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-16 · tag F0640 — patternEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not transmit to the Centers for Medicare/Medicaid (CMS) System information for each resident contained in the Minimum Data Set (MDS) within 7 days after completion. Resident identifiers: 2, 4, 28, 38, 48, 61, and 78. Findings include: 1. Resident 38 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic kidney disease, atrial fibrillation, and congestive heart failure. Resident 38's record was reviewed on 11/14/23. Resident 38's record indicated that an MDS dated [DATE] indicated in the Electronic Health Record (EHR) was export ready. Review of the CMS System indicated that the 8/31/23 MDS for resident 38 had not been transmitted as of 11/14/23. 2. Resident 2 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, bell's palsy and liver transplant status. Resident 2's record was reviewed on 11/14/23. Resident 2's record indicated that an MDS dated [DATE] in the EHR was export…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-16 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined, the facility did not ensure that each resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Specifically, for 3 out of 40 sampled residents, a resident with bilateral hand contractures was not being provided the ordered device to hold in the contracted hand during the day for comfort and prevention. In addition, residents did not received RNA (Restorative Nursing Services). Resident identifiers: 22, 68 and 73. Findings include: 1. Resident 22 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses which included, hemiplegia and hemiparesis following cerebral infarction affecting left and right sides, muscle weakness, contracture of hand and joint, quadriplegia, and limitation of activities due to disability. A review of resident 22's medical records 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 · E2023-11-16 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility did not provide food prepared by methods that conserve nutritive value, flavor, and appearance or palatable, attractive, and at a safe temperature. Specifically, 13 residents complained of food to surveyors, numerous residents filed grievances about the quality of the food served, multiple resident council notes complained of food quality, and a test tray pulled by surveyors was not palatable. Resident identifiers: 1, 2, 6, 12, 27, 41, 53, 54, 55, 61, 71, 86, and 156. Findings include; 1. On 11/14/23 at 1:08 PM, an interview was conducted with Resident 1. Resident 1 stated that the food served by the facility was sickening. Resident 1 stated that when she was admitted to the facility, the admissions coordinator told her husband that he should consider bringing her outside food because the food served by the facility was not great. 2. On 11/14/23 at 9:09 AM, an interview was conducted with Resident 86. Resident 86 stated that he is not allowed to eat eggs or dairy, but that he is frequently served…
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 · D2023-11-16 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
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 40 sampled residents, that the facility did not inform the resident in language that could be understood, of the care to be furnished, of the risks and benefits of the proposed care, of the treatment and treatment alternatives or options and to choose the option that he or she prefers. Specifically, one resident was not aware of the change in their diet order. Resident identifier: 68. Findings include: Resident 68 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease, encephalopathy, protein calorie malnutrition and adult failure to thrive. On 11/15/23 an interview was conducted with resident 68. Resident 68 stated that in the past, he was prescribed a renal diet, but the food provided was horrible and he did not want to eat it. Resident 68 stated that since he did not like the taste of the food served at the facility, he would often order take out food to eat instead. He stated that the facility allowed him…
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 · D2023-11-16 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined for 1 of 40 sampled residents, that the facility did not inform the resident in language that could be understood, of the care to be furnished, of the risks and benefits of the proposed care, of the treatment and treatment alternatives or options and to choose the option that he or she prefers. Specifically, one resident was not aware of the change in their diet order. Resident identifier: 68. Findings include: Resident 68 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease, encephalopathy, protein calorie malnutrition and adult failure to thrive. On 11/15/23 an interview was conducted with resident 68. Resident 68 stated that in the past, he was prescribed a renal diet, but the food provided was horrible and he did not want to eat it. Resident 68 stated that since he did not like the taste of the food served at the facility, he would often order take out food to eat instead. He stated that the facility allowed him…
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 · D2023-11-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review, the facility did not provide a safe, clean, comfortable and homelike environment, allowing the residents to use his or her personal belongings to the extent possible. Specifically, a resident requiring a specialized diet was not allowed to bring in his mini refrigerator to store his food. Resident identifier: 68. Findings include: Resident 68 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease, encephalopathy, protein calorie malnutrition and adult failure to thrive. On 11/15/23 an interview was conducted with resident 68. Resident 68 stated that in the past, he was prescribed a renal diet, but the food provided was horrible and he did not want to eat it. Resident 68 stated that since he did not like the taste of the food served at the facility, he would often order take out food to eat instead. He stated that the facility allowed him to sign a risk vs. benefit form and his diet was then changed to a regular diet.…
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 · D2023-11-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that a resident who received psychotropic drugs were not given these drugs unless the medication was to treat a specific condition as diagnosed and documented in the clinical record. Specifically, a resident who was prescribed a psychotropic medication was given the medication daily with out adequate monitoring. Resident identifier 18. Findings include: Resident 18 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia with behavioral disturbance, major depressive disorder, and anxiety disorder. Resident 18's medical record was reviewed on 11/15/23. A physician's order revealed orders dated 10/11/23 for the following: a. Clonazepam oral tablet 0.25 MG (milligrams) to be given two times a day related to anxiety disorder. b. Seroquel oral tablet, give 100 MG by mouth two times a day for major depressive disorder. c. Trazodone Oral Tablet 50 MG to be given by…
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
$7,525 in federal fines across 1 penalty.
- $7,525 — penalty dated 2024-03-12
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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.8 | -0.8 vs chain |
| Health inspection | 2 of 5 | 2.2 | -0.2 vs chain |
| Staffing | 1 of 5 | 2.8 | -1.8 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 10 homes this chain runs (chain average 2.8★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| MURRAY, BRIAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/01/2018 |
| GUNNISON VALLEY HOSPITAL | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/02/2025 |
| HEALTH GROUP MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| MONUMENT HEALTH GROUP LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| CANTWELL, KALAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| CLAWSON, TRAVIS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| ESPINOSA, STEPHANIE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| FRAGOSO, LINDSAY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| GANGOTENA-BERNARD, FATIMA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| JULIAN, MERANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| ROBERTSON, BRETT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| SAMUELIAN, SPENCER | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| SEASTRAND, JASON | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
| WEST, CHRISTIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/07/2025 |
CMS files one row per role, so the 29 rows in the source record cover these 14 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.
3 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 $6.2M paid to related parties — landlords or management companies under common ownership — equal to about 48% 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
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 465066. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-03, 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 →
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