St. George Rehabilitation
1032 East 100 South, St. George, UT 84770 · For profit - Partnership · 99 certified beds · (435) 628-0488 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2024
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its facility-reported quality-measure score sits well above its independent inspection score
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 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 | 3.7% | 11.3% | 15.4% | better |
| Long-stay residents who lose too much weight | 2.4% | 3.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.7% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.3% | 1.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 7.4% | 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 | 6.2% | 2.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 7.7% | 15.1% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 22.8% | 25.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.2% | 3.9% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.6% | 21.5% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.9% | 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 | 94.1% | 91.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.9% | 16.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 9.8% | 11.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.41 | 1.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.88 | 1.43 | 1.80 | 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 83 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 88.3% 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 60 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 0.71 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 57.9%CMS range 49.2–67.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.9%CMS range 6.5–13.0 | 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 | 88.3% | 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 | 71.7% | 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 | 75.0% | 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 98.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.4% | 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 | 8.2%CMS range 4.6–13.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.03 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 99 beds and averages 96.5 residents a day — about 97% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. 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 3.53 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.84 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.97 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 3.04 hrs/resident/day on weekends vs 3.72 on weekdays — 18% thinner on weekends. RN hours go from 0.90 to 0.67 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 46% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are 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.
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.
24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.
- Potential for harm · Fcited before2024-06-07 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and facility policy review, the facility failed to store, prepare, and serve food in a sanitary manner for 1 of 2 nourishment refrigerators and 1 of 1 kitchen. Specifically, the staff failed to date foods brought in from visitors to be stored in the nourishment refrigerators and discard opened food items that were undated and had been in the nourishment refrigerators for an indeterminate amount of time. Additionally, the staff failed to change gloves and wash their hands after touching high-contact surfaces and before touching food items. This had the potential to affect 96 of 96 residents who received food from the dietary department. Findings included: 1. A facility policy titled, [Facility Name] Policy / Procedure, revised 11/2016. specified, Food or beverage brought in from outside sources for storage in facility pantries, refrigeration units, or personal/resident room refrigeration units will be monitored by designated facility staff for food safety. An undated facility policy titled, Food Storage, specified, Leftover food is stored in covered…
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 · D2024-06-07 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, document review, and policy review, the facility failed to protect residents' rights to be free from verbal abuse and physical abuse by staff and by a resident for 2 (Resident #33 and Resident #47) of 13 sampled residents reviewed for abuse. On 08/21/2023, Licensed Practical Nurse (LPN) #29 was heard by staff to verbally abuse Resident #47. In addition, Resident #145 physically abused Resident #33 on two occasions, on 04/17/2024 resulting in knuckle marks to the resident's forehead and on 04/28/2024 resulting in scratches to the resident's face. Findings included: A facility policy titled, Abuse: Prevention of and Prohibition Against, revised in 02/2024, indicated, It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy specified, Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or…
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 · D2024-06-07 · 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
Based on interview, record review, document review, and policy review, the facility failed to ensure an allegation of verbal abuse was reported immediately to the Administrator for 1 (Resident #47) of 13 sampled residents reviewed for abuse. Specifically, on 08/21/2023 at approximately 7:00 PM/8:00 PM, Certified Nursing Assistant (CNA) 27 and CNA #28 heard Licensed Practical Nurse (LPN) #29 verbally abuse the resident; however, the staff did not report the allegation of abuse to the Administrator until 10:15 PM. Findings included: A facility policy titled, Abuse: Prevention of and Prohibition Against, revised in 02/2024, indicated, 1. All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. An admission Record revealed the facility admitted Resident #47 on 07/28/2022. According to the admission Record, the resident had a medical history that included diagnoses of dementia with behavioral disturbance, anxiety disorder, and need for assistance with personal care. An annual Minimum Data Set (MDS),…
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 · D2024-06-07 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, document review, and policy review, the facility failed to implement their abuse policy for 2 (Resident #47 and Resident #395) of 13 sampled residents reviewed for abuse. Specifically, the facility failed to remove the accused staff member rom care of any resident after staff reported to the Administrator they heard Licensed Practical Nurse (LPN) #29 verbally abuse Resident #47 on 08/21/2023. The facility also failed to interview the alleged perpetrator and other residents when it was alleged that Resident #396 poked Resident #395 in the breast in the hallway on 04/09/2023. Findings included: A facility policy titled, Abuse: Prevention of and Prohibition Against, revised in 02/2024, indicated, 2. After receiving the allegation, and during and after the investigation, the Administrator will ensure that all residents are protected from physical and psychosocial harm. Per the policy, 4. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her…
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 · D2024-06-07 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to develop a care plan to address the supplemental oxygen usage for 2 (Resident #37 and Resident #76) of 2 sampled residents reviewed for respiratory care. Findings included: An undated facility policy titled, Care Planning, indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident and care plans will be updated as necessary with resident changes to help promote optimal care to the resident. 1. An admission Record revealed the facility admitted Resident #37 on 09/05/2023. According to the admission Record, the resident had a medical history that included diagnoses of acute respiratory failure with hypoxia and chronic respiratory failure with hypercapnia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/02/2024, revealed Resident #37 received oxygen therapy. Resident #37's Order Summary Report, for active orders as of 06/04/2024, revealed an order dated 09/05/2023, 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.
- Potential for harm · D2024-06-07 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to revise the care plan to include added new interventions after a fall for 1 (Resident #86) of 4 sampled residents reviewed for accidents. Findings included: An undated facility policy titled, Care Planning, indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident and care plans will be updated as necessary with resident changes to help promote optimal care to the resident. The policy indicated, 7. Care plans will be updated with resident changes to promote optimal resident care. An admission Record indicated the facility admitted Resident #86 on 03/29/2024. According to the admission Record, the resident had a medical history that included diagnoses of cerebral infarction (stroke) due to embolism of right middle cerebral artery and essential primary hypertension (high blood pressure). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/05/2024, revealed Resident #86 had a Brief…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-07 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to follow a physician's order to hold a nicotine patch when the resident was smoking for 1 (Resident #86) of 4 sampled residents reviewed accidents. Findings included: An admission Record indicated the facility admitted Resident #86 on 03/29/2024. According to the admission Record, the resident had a medical history that included diagnoses of cerebral infarction (a stroke) due to embolism of right middle cerebral artery and essential primary hypertension (high blood pressure). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/05/2024, indicated Resident #86 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. Resident #86's care plan, initiated on 04/16/2024, indicated the resident had the potential for injury related smoking. Resident #86's Medication Administration Record [MAR], for June 2024, revealed a transcription of an order dated 05/22/2024, for nicotine patch 24 Hour, 7 milligrams…
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 · D2024-06-07 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of manufacturer's information, the facility failed to ensure they maintained a medication error rate of less than 5 percent (%). The facility had 2 errors out of 34 opportunities, resulting in a medication error rate of 5.88 %, affecting 1 (Resident #14) of 3 residents observed during medication administration. Findings included: An admission Record indicated the facility admitted Resident #14 on 03/04/2021. According to the admission Record, the resident had a medical history that included a diagnosis of type two diabetes mellitus with diabetic neuropathy. Resident #14's Order Summary Report, listing active orders as of 06/07/2024, contained an order, dated 07/25/2023, for insulin glargine subcutaneous solution 100 units per milliliter (units/mL), inject 75 units subcutaneously every morning and at bedtime for type two diabetes mellitus. The Order Summary Report also contained an order, dated 03/04/2021, for NovoLog Solution 100 units/mL, inject as per sliding scale (a progressive increase in insulin dose, based upon predefined blood…
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 · E2023-01-12 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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, for 4 of 24 sampled residents, that the facility did not provide each resident with a safe, clean homelike environment. Specifically, a resident had plastic in the corner of her room where the roof had leaked, there were gashes in the drywall behind a resident's bed, wheelchair was soiled, and rooms had trash and debris on the floor. Resident identifiers: 8, 28, 73 and 128. Findings included: 1. On 1/9/23 at 4:16 PM, resident 73 was interviewed. Resident 73 stated that approximately 1 week ago, it had rained and that the wall and ceiling near the window had leaked water. Resident 73 stated that the maintenance stopped by and told her the room was being looked at. Resident 73 stated that the ceiling and wall leaked one more time a few days after the initial leak. Resident 73 stated the facility did not offer a room change. An observation was made of resident 73's room, room [ROOM NUMBER]. The ceiling and wall in the corner of resident 73's room was covered…
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 · D2023-01-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 24 sample residents, that a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition. Specifically, a Speech Language Pathologist (SLP) wrote a physician's order to provide a resident with maximum assistance with eating and the resident was observed to be eating in her room without assistance. Resident identifier: 127. Findings include: Resident 127 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included displaced intertrochanteric fracture of right femur, dysphagia, type 2 diabetes mellitus, Alzheimer's disease, dementia, major depressive disorder, anxiety and scabies. On 1/10/23 at 10:00 AM, an interview was conducted with resident 127's family member. The family member stated resident 127 had lost a lot of weight. The family member stated Registered Nurse (RN) 1 told her that resident 127 fed herself. The family member stated that…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 14 citations
- Potential for harm · D2023-01-12 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 1 of 24 sampled residents, that the facility did not ensure proper treatment and assistive devices to maintain vision abilities. Specifically, a resident with dementia's glasses were missing and staff were not aware. Resident identifier: 127. Findings include: Resident 127 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included displaced intertrochanteric fracture of right femur, dysphagia, type 2 diabetes mellitus, Alzheimer's disease, dementia, major depressive disorder, anxiety and scabies. On 1/10/23 at 9:59 AM, a phone interview was conducted with resident 127's family member. The family member stated resident 127's glasses had been missing for over 2 years. The family member stated resident 127 had multiple falls which might have been from not being able to see. On 1/10/23 at 8:46 AM, an observation was made of resident 127 in the memory care unit dining room. Resident 127 did not have glasses on. 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 · Dcited before2023-01-12 · 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 24 sampled residents, that the facility did not ensure that residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed in the clinical record. Specifically, a resident was prescribed an anti-psychotic medication without a supporting clinical diagnosis and no gradual dose reduction. Resident identifier 11. Findings include: Resident 11 was admitted to the facility on [DATE] with diagnoses which include,Cerebral infarction, Major depressive disorder, recurrent, Unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and Cognitive communication deficit. Review of resident 11's physician's orders revealed the following: a. Quetiapine 25 milligram (mg), give 25 mg by mouth in the evening for major depressive disorder (MDD). The order was initiated on 3/8/22. Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 11…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-12 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there was dust in a vent above the food preparation area, food splatter on the ceiling, uncooked bacon stored above ready to eat food, an open beverages was not dated, and another beverage was served after the use by date. Findings included: On 1/11/23 at 11:28 AM, an initial tour of the kitchen was conducted. The following was observed: a. There were food splatters on the ceiling above food preparation areas. b. There was dust in a ceiling vent directly over a food preparation station c. There were food splatters above the clean dish area of the dishwashing room. There was a fan with dust blowing onto the clean dish area. d. There was a package of uncooked bacon stored above butter in the refrigerator. The pack date was listed as November 12th 2022. 2. On 1/11/23 at 12:34 PM, an observation was made of the 200 hallway dining room. There was a container of Soy milk in an ice bath…
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 · D2023-01-12 · tag F0914 — isolatedProvide bedrooms that don't allow residents to see each other when privacy is needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview it was determined, for 1 of 24 sample residents, that the facility did not ensure that each shared room bed had ceiling suspended curtains, which extend around the bed to provide full visual privacy in combination with adjacent walls and curtains. Resident identifier 127. Findings included: On 1/11/23 at 1:05 PM, an observation was made of resident 127. Resident 127 was observed in bed with a sheet over her. Certified Nursing Assistant (CNA) 3 was observed to turn and pull resident 127's privacy curtain and there was no privacy curtain. Resident 127's roommate and visitor were in the room. CNA 3 stated she did not know why resident 127 did not have a privacy curtain to cover her bed. CNA 3 was observed to stand between resident 127 and her roommate to try and cover resident 127 while she changed the sheet. Resident 127 was observed in a brief and shirt under the sheet. On 1/12/23 at 8:00 AM, staff were observed changing resident 127 in a shared room. Resident 127 did not have a privacy curtain and resident 127's roommate was in the room during this…
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 · E2021-05-20 · tag F0808 — failed to follow doctor-ordered diets — patternEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record reviews it was determined, for 4 of the 34 residents, that the facility did not provide therapeutic diets prescribed by the attending physician or licensed dietitian. Specifically, 4 residents had orders in their electronic medical record for consistent carbohydrate diet (CCHO) and were provided a regular diet per their meal tray tickets. Resident identifiers: 22, 32, 51, 257. Findings include: 1. On 5/17/21 at 5:33 PM, during dinner meal tray pass resident 22's tray ticket was observed to read, Diet Order: *REGULAR. On review of resident's electronic medical record his diet order read CCHO diet. 2. Tray tickets, diet orders and nutrition evaluation notes were reviewed for consistency in diet orders. a. Resident 22 was admitted to the facility on [DATE] with medical diagnoses that included hemiplegia and hemiparesis following cerebral infarction, dysarthria following cerebral infarction, dysphagia following cerebral infarction, type 2 diabetes mellitus without…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-05-20 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview it was determined the facility did not store, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility's resident refrigerator had items stored without being labeled with names and/or dates, the facility's kitchen had items not dated and labeled or left open to air in the refrigerators with an observation of a used rag found within the refrigerator next to an opened package or deli meat, and beverages and salad dressings on residents trays were observed being transported from the meal cart to resident rooms without being covered. Findings Include: 1. The resident refrigerators were inspected on 5/19/21 and 5/20/21. The following observations and interviews were conducted regarding the resident refrigerator: a. On 5/19/21 at 4:05 PM, the resident fridge near 500 hall contained a take-out Chinese food box without a date in which it had been placed in the fridge. b. On 5/19/21 at 4:05 PM, the resident fridge near 500 hall contained a panda express take out container with the resident's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-20 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
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 34 sampled residents, that the facility did not ensure that the receiving health care institution had the resident's medical record information including; the contact information of the practitioner responsible for the care of the resident, resident representative information, advance directive information, special instructions for ongoing care, comprehensive care plan, and any other documentation to ensure a safe and effective transition of care. Specifically, the resident was transferred to the local area hospital emergency department (ED) without any accompanying medical records. Resident identifier 4. Findings include: Resident 4 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2, chronic kidney disease, osteoporosis, major depressive disorder, anxiety disorder, nephropathy, gastro-esophageal reflux disease, neuromuscular dysfunction of the bladder,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-20 · tag 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 it was determined, for 1 of 34 sampled residents, that the facility did not ensure that the resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which would indicate the dose should be reduced or discontinued; or any combinations of these reasons. Specifically, a resident was administered Diltiazem when it should have been held per facility wide physician parameters. Resident identifier 42. Findings include: Resident 42 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included hypertension, atrial fibrillation, chronic fatigue, chronic obstructive pulmonary disease, diabetes mellitus, dementia, major depressive disorder, anxiety disorder, and restless leg syndrome. On 5/18/21 resident 42's medical records were reviewed. Review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2021-05-20 · 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 34 sampled residents, that the facility did not ensure that residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed in the clinical record. Specifically, a resident was prescribed an anti-psychotic medication without a supporting clinical diagnosis. Resident identifier 55. Findings include: Resident 55 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses which included dementia with behavioral disturbance, cognitive communication deficit, major depressive disorder, unspecified fracture of the right femur, history of falling, pain right ankle, muscle weakness, scoliosis, low back pain, gastro-esophageal reflux disease, chronic pain syndrome, dysphagia, foot drop of right foot, hypothyroidism, hypertension, pain left hip, macular degeneration, syncope and collapse, anemia, and osteoarthritis. Review of resident 55's orders revealed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-20 · tag F0807 — failed to offer suitable drinks — isolatedEnsure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
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 the 34 sampled residents, the facility did not provide each resident with drinks, including water and other liquids consistent with the residents' needs and preferences and sufficient to maintain resident hydration. Specifically, a resident with a physician orders for thickened liquids was observed with regular water and juice at the bedside, and care staff were observed to be unaware of the resident's liquid consistency or the procedure for mixing thickened liquids at meal times. Resident identifier 22. Findings include: 1. Resident 22 was admitted to the facility on [DATE] with medical diagnoses which included hemiplegia and hemiparesis following cerebral infarction, dysarthria following cerebral infarction, dysphagia following cerebral infarction, type 2 diabetes mellitus without complications, chronic obstructive pulmonary disease, chronic respiratory failure, difficulty in walking, cognitive communication deficit, neuromuscular…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-20 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review it was determined, for 1 of the 34 sampled residents, the facility did not maintain medical records on each resident that were complete and readily accessible. Specifically, the facility did not keep a complete, readily-accessible record of a resident's hemodialysis treatment and dialysis communication records. Resident identifier 31. Findings include: Resident 31 was admitted to the facility on [DATE] with medical diagnoses that included Alzheimer's disease, end stage renal disease with dependence on renal dialysis, metabolic encephalopathy, diabetes mellitus, atrial fibrillation, hypertension, acquired absence of right leg below knee, heart disease, dysphagia, attention and concentration deficit, and acute kidney failure. Resident 31's orders within her electronic medical record were reviewed on 05/19/21 at 10:18 AM. Orders indicated, RESIDENT HAS DIALYSIS ON: MWF (Monday, Wednesday, Friday) DIALYSIS CENTER: [name of company] TRANSPORT & PICK-UP TIME: 1100…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-20 · tag F0867 — failed to act on quality-improvement findings — isolatedSet 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, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented plans of action to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance for the same deficiencies identified in the last annual recertification survey. Findings include: An annual recertification survey was completed on 4/3/19. During that survey F623, F712, F757, F758, and 761 were cited. An annual recertification survey was completed on 5/20/2021. During that survey F757 and F758 were identified as repeat deficiencies. 1. Based on interview and record review it was determined, for 1 of 34 sampled residents, that the facility did not ensure that the resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which would indicate the dose should be reduced or discontinued; or any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-20 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined, for 1 of 34 sampled residents, that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. Specifically, hand hygiene was not performed prior to entering and exiting a resident room, and gloves were not donned prior to performing direct patient care. Resident identifier 48. Findings include: Resident 48 was admitted to the facility on [DATE] with diagnoses which included unspecified intracranial injury, traumatic brain injury, aphasia, anxiety disorder, hypertension, and gastrostomy status. On 05/19/2021 at 8:54 AM, an observation was made of Registered Nurse (RN) 2 performing her morning medication pass. At 8:55 AM, RN 2 entered a resident 48's without hand sanitizing or donning gloves. RN 2 turned off the resident's feeding pump and disconnected the feeding tube from the resident. RN 2 hung the feeding tube on the intravenous (IV) pole then…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-05-20 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 of 34 sampled residents, that the facility did not ensure that each resident was offered an Influenza and Pneumococcal immunization and that the medical records included documentation that the resident either received the immunization or did not due to contraindications or refusal. Specifically, one resident did not have Influenza immunization documentation in the medical record. Additionally, a second resident did not receive a Pneumococcal immunization until after the survey had started and the facility was asked about it. Resident identifiers: 42 and 47. Findings include: On 5/18/21 at approximately 10:38 AM, an interview was conducted with the facility's Infection Preventionist (IP). The IP reviewed her computer spreadsheets for immunization information on 5 current residents selected for review. Information about resident 42's Influenza immunization and resident 47's Pneumococcal immunization could not be found in the IP's immunization…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.2 | +0.8 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 3 of 5 | 2.7 | +0.3 vs chain |
| Quality measures | 5 of 5 | 4.4 | +0.6 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| COSGRAVE, CORY | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/11/2023 |
| HOOPES, TRAVIS | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/01/2016 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | since 12/01/2016 |
| KEETCH, CHAD | Individual | CORPORATE OFFICER | since 03/01/2011 |
| MOSS, TYLER | Individual | CORPORATE OFFICER | since 01/01/2019 |
| SAND HOLLOW HEALTHCARE INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/24/2025 |
| ENSIGN SERVICES INC | Organization | ADP OF THE SNF | since 05/01/2015 |
| QUAIL CREEK HEALTH HOLDINGS LLC | Organization | ADP OF THE SNF | since 12/01/2016 |
| STANDARD BEARER HEALTHCARE OP, LP | Organization | ADP OF THE SNF | since 12/01/2016 |
| THE ENSIGN GROUP INC | Organization | ADP OF THE SNF | since 12/01/2016 |
CMS files one row per role, so the 15 rows in the source record cover these 10 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 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 10% 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 465064. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-06-07, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.