Copper Ridge Health Care
3706 West 9000 South, West Jordan, UT 84088 · For profit - Corporation · 120 certified beds · (801) 280-2273 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (17) — 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 independent health-inspection rating is low (2/5)
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) | 3 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
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 4 to 5 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 | 13.6% | 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 | 3.0% | 0.7% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.8% | 1.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 12.2% | 16.5% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.5% | 0.1% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 0.0% | 2.5% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 15.7% | 15.1% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 19.7% | 25.3% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.5% | 3.9% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 33.3% | 21.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 11.9% | 14.2% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 0.9% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 98.9% | 91.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 18.2% | 16.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 10.2% | 11.6% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.74 | 1.25 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.30 | 1.43 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
68.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 115 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 67.5% 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 80 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 0.57 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% 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 | 68.5%CMS range 60.5–75.9 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.7%CMS range 6.7–13.4 | 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 | 67.5% | 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 | 72.5% | 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 | 61.2% | 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 | 95.8% | 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 | 98.6% | 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 | 1.1% | 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 | 6.0%CMS range 3.5–10.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.80 | 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 120 beds and averages 92.5 residents a day — about 77% occupied, or roughly 28 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.80 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.03 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 2.83 hrs/resident/day on weekends vs 3.71 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.91 to 0.53 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 11 most serious are shown; the remaining 6 are one tap away and print in full.
- Immediate jeopardy · J2026-06-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 8 sampled residents (Resident 8). Specifically, facility staff failed to respond to a wander guard alarm, failed to communicate with one another, and failed to implement the facility's elopement procedure when Resident 8, a cognitively impaired resident with known exit-seeking behaviors, eloped from the building. Resident 8 was found by police approximately 1.5 hours later near a fast-food restaurant two miles away, having sustained a self-reported fall and facial bruising. This noncompliance placed Resident 8 at risk for serious injury, serious harm, serious impairment, or death, constituting an Immediate Jeopardy.It was determined the provider's noncompliance with the requirements of participation had caused a situation that constituted Immediate Jeopardy. The noncompliance was related to the State Operations Manual, Appendix PP, S483.25(d)(2) Adequate supervision to prevent accidents, F689,…
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 · D2025-09-10 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, for 1 out of 43 sampled residents, the facility did not ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a resident did not have a physician order for their use of oxygen. Resident identifier: 29.Findings included:Resident 29 was admitted to the facility on [DATE] with diagnoses which included acute pyelonephritis, pneumonia due to other specified infectious organisms, and acute kidney failure.On 9/7/25 at 10:39 AM, an observation was made of resident 29, she was wearing a nasal cannula, and an operating oxygen concentrator set at 5 liters (L) was next to resident 29's bed.On 9/9/25 at 11:50 AM, an observation was made of resident 29, she was returning to the facility, she had on a nasal cannula with a portable oxygen tank set at 4 L. On 9/10/25 at 10:04 AM, an observation was made 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 · D2025-09-10 · tag F0775 — isolatedKeep complete, dated laboratory records in the resident's record.
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, for 1 out of 43 sampled residents, the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Resident identifier: 89Findings Included: Resident 89 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, spastic hemiplegia, immobility syndrome (paraplegic), and metabolic encephalopathy. Resident 89's medical record was reviewed on 9/7/25 through 9/10/25. A review of resident 89's progress notes revealed:On 6/24/25 at 5:35 PM, a nursing note documented, Resident was seen provider [sic] today, order received to get KUB [kidney, ureter, bladder x-ray] and UA [urinalysis]. Sample sent to lab and KUB performed, Results were related to provider.On 6/25/25 at 12:40 PM, a laboratory/radiology note documented, 6/23/24 [sic] UA [urinalysis] results back, provider notified. Set up for culture.On 6/28/25 at 7:34 AM, a nursing note…
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 · D2025-09-10 · 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 interview and record review, for 1 out of 43 sampled residents, the facility did not arrange services with an outside agency in a timely manner. Specifically, a resident did not have a follow up appointment scheduled within the timeline ordered by the provider after a surgical procedure. Resident identifier: 18.Findings included:Resident 18 was admitted to the facility on [DATE] with diagnoses which included right femur fracture, unspecified protein-calorie malnutrition, and dementia.On 9/7/25 at 10:28 AM, an interview was conducted with resident 18's family member. Resident 18's family member stated that the facility forgot about resident 18's orthopedic follow-up visit. The family member stated that resident 18's follow up visit was supposed to be two weeks after her surgery was performed. Resident 18's family member stated that the information was given to the facility when she was admitted .Resident 18's medical record was reviewed on 9/7/25 through 9/10/25. Resident 18's hospital discharge orders…
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 · E2023-11-02 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that medication error rates were not 5 percent or greater. Observations of 25 medication opportunities, on 11/2/23, revealed 3 medication errors which resulted in a 12.00% medication error rate. Specifically, two blood pressure medications were not administered to a resident and a medication was administered at the wrong time. Resident identifier: 63. Findings included: Resident 63 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute and chronic respiratory failure, chronic kidney failure stage 4, type 2 diabetes, morbid obesity, essential hypertension, and hypothyroidism. Resident 63's medical record was reviewed on 11/2/23. On 11/2/23 at 9:00 AM, an observation was made of Registered Nurse (RN) 1 during morning medication administration on the bottom of the 200 hallway. RN 1 had dispensed five medications for resident 63 into a medication cup, Synthroid was observed to be one…
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 · E2023-11-02 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
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 residents were free of any significant medication errors. Specifically, for 1 out of 31 sampled residents, a resident's Humalog was administered when it should have been held, Lantus was not increased to 78 units, hold blood glucose (BG) parameters were not lowered to 160, and an as needed (PRN) Humalog order was not initiated. Resident identifier: 54. Findings included: Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, pain in thoracic spine, dementia, bipolar 2 disorder, type 2 diabetes mellitus, cognitive communication deficit, chronic kidney disease stage 3, generalized anxiety disorder, major depressive disorder, and chronic pain. Resident 54's medical record was reviewed on 10/31/23. On 6/22/23, a physician's order documented Lantus Subcutaneous Solution 100 UNIT/ML [milliliters] (Insulin Glargine) Inject 74 unit subcutaneously at bedtime related to TYPE 2…
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 · D2023-11-02 · 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, interview, and record review, the facility did not provide procedures that assure the accurate recording of narcotics. Specifically, for 2 out of 9 sampled residents, licensed nursing staff did not reconciliate narcotics in accordance with professional standards and principles. Resident identifiers: 32 and 67. Findings included: 1. Resident 32 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included spastic hemiplegic cerebral palsy, chronic kidney disease, dementia, cognitive communication deficit, pain in left hip, muscle weakness, and major depressive disorder. Resident 32's medical record was reviewed on 11/2/23. Resident 32's physician's orders included an order for Oxycodone HCL [hydrochloride] 5 mg [milligrams], give 2.5 mg three times a day by mouth for PAIN, 1/2 tab [tablet]. The paper narcotic record on the Bottom of the 200 Hallway medication cart revealed that resident 32 had the following anomaly on the Controlled Drug Receipt…
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 · D2023-11-02 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 irregularities noted by the pharmacist during the drug regimen review must be reported to the attending physician and the facility's Medical Director (MD) and Director of Nursing (DON), and these reports must be acted upon. Specifically, for 1 out of 31 sampled residents, a pharmacy recommendation to discontinue a resident's medication was not acted upon when the MD agreed with the pharmacy recommendation. Resident identifier: 54. Findings included: Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, pain in thoracic spine, dementia, bipolar 2 disorder, type 2 diabetes mellitus, cognitive communication deficit, chronic kidney disease stage 3, generalized anxiety disorder, major depressive disorder, and chronic pain. Resident 54's medical record was reviewed on 10/31/23. The pharmacy Patient Reviews Log dated 6/24/23, documented This resident has an order for Aspirin 81 mg [milligrams] daily…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-02 · 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 that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 31 sampled residents, a resident's cardiac medication for hypertension was not held when the systolic blood pressure (SBP) was below the physician's ordered parameters. Resident identifier: 30. Findings included: Resident 30 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, spina bifida with hydrocephalus, major depressive disorder, separation anxiety disorder of childhood, post traumatic stress disorder, and dependence on wheelchair. Resident 30's medical record was reviewed on 10/31/23. On 6/28/23, 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 · D2023-11-02 · 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, the facility did not ensure that residents who used psychotropic drugs received gradual dose reductions (GDR) unless clinically contraindicated, in an effort to discontinue these drugs. A GDR must be attempted in two separate quarters, with at least one month between attempts, within the first year in which an individual was admitted on a psychotropic medication or after the facility had initiated such medication, and then annually. Specifically, for 1 out of 31 sampled residents, a resident taking psychotropic that were last increased on 12/16/21 and 6/14/21, had not received a GDR and the medication was not clinically contraindicated. Resident identifier: 54. Findings included: Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, pain in thoracic spine, dementia, bipolar 2 disorder, type 2 diabetes mellitus, cognitive communication deficit, chronic kidney disease stage 3, generalized anxiety…
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 · D2023-11-02 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility did not label all drugs and biological's used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, an insulin pen was not labeled with a resident identifier or an open date and was open and available for use. In addition, narcotics were repackaged into the narcotic cards. Findings included: 1. On 11/2/23 at 9:00 AM, an observation was made of the bottom of the 200 hallway medication cart with Registered Nurse (RN) 1. A pre-filled pen of Basaglar 100 units/milliliter was open and available for use. The pen had no resident identifier information and no open date could be seen. On 11/2/23 at 9:04 AM, an interview was conducted with RN 1. RN 1 stated there was no name on the insulin ben and that he did not know who the insulin pen belonged to. RN 1 was observed to place the insulin pen back into the medication cart for future use. 2. On 11/2/23 at 9:20 AM, an observation was made of the 100 hallway medication…
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 6 citations
- Potential for harm · E2022-01-12 · 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, for 7 of 31 sample residents, that the facility did not provide food and drink that was palatable, attractive, at at a safe and appetizing temperature. Specifically, residents complained of the food quality, a test tray was not palatable, and there were complaints of food quality in resident council. Resident identifiers: 9, 21, 24, 47, 57, 77 and 82. Findings include: 1. On 1/10/22 at 1:48 PM, resident 77 was interviewed. Resident 77 stated that the food was Nasty. On 1/11/22 at 3:24 PM, resident 82 was interviewed. Resident 82 stated the food was not good. On 1/10/22 at 10:57 AM, resident 24 was interviewed. Resident 24 stated that the food was not very good. A follow up interview was conducted on 1/12/22 at 7:57 AM, resident 24 that they only serve salty things, and the same thing over and over. On 1/10/22 at 1:43 PM, resident 57 was interviewed. Resident 57 stated that the food was too salty and sometimes not edible. Resident 57 stated that the facility did not provide him alternative food items. On 1/10/22 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-01-12 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff were not using N95 masks for a resident with isolation precautions, staff were not wearing appropriate eye protection and staff taking soiled gowns through the hallway after leaving an isolation room. Findings include: 1. On 1/11/22 at 12:01 PM, an observation was made of room [ROOM NUMBER]. There was a sign that revealed droplet precautions and a sign indicating to see the nurse before entering. Speech, Language, Pathologist (SLP) 1 was exiting room [ROOM NUMBER] with fabric gown on and a water mug. SLP 1 was observed to place the mug on top of a plastic bin with Personal Protective Equipment (PPE) inside the bin. SLP 1 was observed to removed the fabric gown and place it between his legs. SLP 1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-01-12 · tag F0886 — failed to test for COVID-19 as required — patternPerform COVID19 testing on residents and staff.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined, for 2 of 5 sampled facility staff, that the facility did not ensure that routine testing of staff for COVID-19 was completed based on the parameters set forth by the Secretary. Specifically, routine testing of unvaccinated staff for COVID-19 at a frequency of two times per week during periods of high levels of community transmission, based on the positivity rate of the county the facility was located in, was not followed. Staff identifiers: Staff 1 and Staff 5. Findings include: On 1/11/22, the facility's staff vaccination log and staff testing log was provided. Staff 1 and Staff 5 were documented as having refused to be vaccinated against COVID-19. The testing log records for October 2021, November 2021, December 2021, and January 2022 were reviewed. According to the Centers for Disease Control and Prevention (CDC) the community transmission where the facility is located was high, identified as red, for the weeks of 12/6/21, 12/13/21, 12/20/21, 12/27/21, 1/3/22, and 1/10/22. (Source:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-01-12 · tag F0923 — patternHave enough outside ventilation via a window or mechanical ventilation, or both.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility did not ensure that ventilation in the hallways was sufficient to keep foul odors from the hallways. Specifically, odors of urine and feces were observed in the hallways and resident common areas. Findings include: 1. On 1/11/22 at 11:42 AM, a stool odor was observed in the 300 East hall. 2. On 1/11/22 at 1:44 PM, a strong odor of urine and smoke was observed in the 300 hall between rooms 304 to 309. 3. On 1/11/22 at 1:46 PM, a strong odor of feces was observed outside rooms 214-218. 4. On 1/11/22 at 1:50 PM, a strong odor of feces was observed in the hallway outside room [ROOM NUMBER]. 5. On 1/12/22 at 10:11 AM, a strong feces odor was observed in the front lobby. 6. On 1/12/22 at 10:14 AM, a strong feces odor was observed outside rooms 217-214. 7. On 1/12/22 at 10:30 AM, an odor of cigarette smoke and urine was observed in the 300 hallway. 8. On 1/12/22 at 12:45 PM, an observation that visitor restrooms ventilation system was not working. 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 · D2022-01-12 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
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 31 sample residents, the facility did not conduct periodic comprehensive, accurate, standardized reproducible assessment not less than once every 12 months. Specifically, resident's annual Minimum Data Set (MDS) assessments were not completed. Resident identifier: 1 and 2. Findings included: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included symptoms and signs involving respiratory and circulatory system, COVID-19, type 2 diabetes, dementia, heart failure, reduced mobility. Resident 1's annual MDS had an assessment reference date (ARD) of 10/25/21. The MDS was ready for export and had not been submitted. 2. Resident 2 was admitted to the facility on [DATE] with diagnoses which included, but not limited to multiple sclerosis, muscle weakness, opioid dependence, drug induced constipation, neuromuscular bladder dysfunction, hypothyroidism, anxiety and type 2 diabetes. Resident 2's annual MDS assessment had an ARD 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 · D2022-01-12 · tag F0924 — isolatedPut firmly secured handrails on each side of hallways.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation it was determined the facility did not ensure hand rails were completely secured to the wall. Specifically, hand rails were not secured throughout the facility. Findings included: On 1/11/22 at 12:05 PM, an observation was made of the 300 hallway. The handrails between room [ROOM NUMBER] and the North Door Exit were not secured to the wall. There were handrail between room [ROOM NUMBER] and corner of hall that were not secured to the wall. There were handrails out side room [ROOM NUMBER] not secured.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 3.2 | -0.2 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 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 |
|---|---|---|---|
| DURTSCHI, LUKE | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/28/2023 |
| GANGOTENA-BERNARD, FATIMA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/20/2024 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | since 10/01/2009 |
| KEETCH, CHAD | Individual | CORPORATE OFFICER | since 03/01/2011 |
| MOSS, TYLER | Individual | CORPORATE OFFICER | since 05/01/2016 |
| JORDAN HEALTH ASSOCIATES, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 05/01/2016 |
| CARETRUST GP LLC | Organization | ADP OF THE SNF | since 05/01/2016 |
| CARETRUST REIT INC | Organization | ADP OF THE SNF | since 05/01/2016 |
| CTR PARTNERSHIP LP | Organization | ADP OF THE SNF | since 05/01/2016 |
| ENSIGN SERVICES INC | Organization | ADP OF THE SNF | since 10/01/2009 |
| JORDAN HEALTH PROPERTIES LLC | Organization | ADP OF THE SNF | since 05/01/2016 |
CMS files one row per role, so the 16 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 11% 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 465108. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-10, 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.