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Alpine Meadow Rehabilitation and Nursing

2520 South Redwood Road, West Valley City, UT 84119 · Government - City/county · 42 certified beds · (801) 972-1050 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Oct 20242 immediate-jeopardy citations$15,025 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Oct 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
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $15,025 in federal fines (most recent 2023-08-24)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • nursing-staff turnover (67%) runs well above the national median (45%)
  • about 35% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 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

Hospital
Urgent care / clinic
2390 S Redwood Rd · (801) 975-1600 · Call to confirm hours
Pharmacy
2446 S 1940 W · (877) 418-4114 · Call to confirm hours
Grocery
명동길 34 · +82332542558 · Call to confirm hours
Park
2300 W Parkway Blvd · (385) 468-7275 · Typically dawn to dusk
Place of worship
1680 W Stratford Ave · (801) 973-7070

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

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased1.4%11.3%15.4%better
Long-stay residents who lose too much weight0.7%3.4%5.4%better
Long-stay residents with a catheter left in their bladder0.0%0.7%0.9%better
Long-stay residents with a urinary tract infection0.0%1.8%2.0%better
Long-stay residents with depressive symptoms13.5%16.5%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury0.7%2.5%3.3%better
Long-stay residents whose ability to walk worsened7.2%15.1%16.1%better
Long-stay residents on antianxiety or hypnotic medication12.9%25.3%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%98.0%95.3%typical
Long-stay residents with pressure ulcers3.0%3.9%4.7%better
Long-stay residents with worsening bladder/bowel control18.8%21.5%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table10.9%14.2%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%0.9%1.4%better
Long-stay hospitalizations per 1,000 resident days1.631.251.67typical
Long-stay outpatient ER visits per 1,000 resident days1.041.431.80better

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.

0.13U.S. median 0.31
Therapy hours / resident / day
0.05hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.13 therapist hours per resident per day in 2026Q1 — more than 9% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 dischargenot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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

0.84
RN hours/ resident / day
0.25
LPN hours/ resident / day
1.45
Aide hours/ resident / day
2.54
Total nurse hours/ resident / day
0.50
RN hoursweekends
66.7%
Total nursing turnover
44.4%
RN turnover

How full it usually is: this home is certified for 42 beds and averages 40.2 residents a day — about 96% 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 2.54 hrs/resident/day is below 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 1.45 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 2.23 hrs/resident/day on weekends vs 2.66 on weekdays — 16% thinner on weekends. RN hours go from 0.98 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 67% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

6
deficiencies at the latest standard inspection (2026-04-22)
2
at the previous standard inspection (2025-04-03)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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.

23 citations, most serious first. The 12 most serious are shown; the remaining 11 are one tap away and print in full.

  • Immediate jeopardy · J2023-08-24 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, it was determined for 4 out of 13 sampled residents, that the facility failed to ensure that the residents environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident received and partially consumed a meal that had not been mechanically altered per the physician orders which resulted in the resident choking on the food and requiring emergency medical attention. Additionally, 3 other residents received and/or consumed meals that were not mechanically altered per the physician orders. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifier: 1, 5, 6, and 14. NOTICE On 8/23/23 at 4:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify hazard(s) and risk(s); evaluate and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Immediate jeopardy · J2023-08-24 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    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 4 out of 13 sampled residents, that the facility failed to ensure that the residents received food prepared in a form designed to meet their individual needs. Specifically, a resident received and partially consumed a meal that had not been mechanically altered per the physician orders which resulted in the resident choking on the food and requiring emergency medical attention. Additionally, 3 other residents received and/or consumed meals that were not mechanically altered per the physician orders. These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifier: 1, 5, 6, and 14. NOTICE On 8/23/23 at 4:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to observe meals and food preparation to assure the food was prepared and appropriate to meet the resident's needs according to…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-22 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure 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 facility did not ensure that the irregularities reported by the pharmacist to the attending physician and Medical Director (MD) were acted upon. In addition, the facility did not ensure the attending physician documented in the resident's medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address it. Specifically, for 5 out of 20 sampled residents, pharmacy recommendations were not acted upon by the MD and the MD did not document the identified irregularity and what action was taken in the resident's medical record. Resident identifiers: 10, 18, 19, 24, and 34.Findings included:1. Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, dementia, and paranoid schizophrenia. The facility Pharmacy Consult for March 2026 was reviewed. The recommendation for the physician documented, [Name redacted], [resident 18] uses Lantus and sliding scale…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-22 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 the resident right to self-administer medications was clinically appropriate and safe. Specifically, for 1 out of 20 sampled residents, a resident was observed to have medication in their room and was not evaluated to determine if they were safe to self-administer that medication. Resident identifier: 1.Findings included:Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, personal history of pneumonia (recurrent), and pneumonitis due to inhalation of food and vomit.On 4/19/26 at 8:23 AM, an observation and interview were conducted with resident 1. A nebulizer machine and three vials of medication were observed on resident 1's night stand. Resident 1 stated the vials contained his nebulizer medication, which he administered throughout the day. Resident 1 stated…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-22 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure 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 20 sampled residents, a resident taking two types of diuretics had those diuretics administered at the same time when they should have been 30 minutes apart. Resident identifier: 10.Findings included:Resident 10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, heart failure, systolic congestive heart failure, essential hypertension. A physician's order dated 4/1/26, documented metOLazone Oral Tablet 5 MG [milligrams] (Metolazone) Give 5 mg by mouth every 48 hours related to HEART FAILURE, UNSPECIFIED . *GIVE 30 MINUTES PRIOR TO BUMEX [bumetanide].A physician's order dated 4/1/26, documented Bumetanide Oral Tablet 2 MG (Bumetanide) Give 3 mg by mouth every 48 hours related to HEART FAILURE, UNSPECIFIED.The April 2026 Medication Administration Record was reviewed. The metolazone and bumetanide…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-22 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 1 out of 20 sampled residents, staff did not wear personal protective equipment (PPE) during wound care for a resident that should have been on Enhanced Barrier Precautions (EBP). Resident identifier: 34.Findings included:Resident 34 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, unspecified open wound of lower back and pelvis without penetration into retroperitoneum.A physician's order dated 4/8/26, documented SKIN TX [treatment] to chronic pilonidal ulcer: cleanse, pack with collagen sheet, cover with bordered dressing. every day shift.Resident 34 was observed to not have EBP signage outside his door or PPE available for use.On 4/20/26 at 10:30 AM, an…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-22 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop 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, the facility did not ensure that residents were offered the influenza vaccine and that the medical record included documentation that the resident either received the vaccine or did not due to medical contraindications or refusal. Specifically, for 1 out of 5 sampled residents, there was no documentation of declination of the influenza vaccine. Resident identifier: 19.Findings included: Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include, but were not limited to, neurocognitive disorder with Lewy bodies.A review of resident 19's immunizations in the medical record documented the last influenza vaccine was completed on 10/25/24. There was no documentation for the current 2025/2026 influenza season.On 4/22/26 at 11:09 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated they did not have the requested documentation for resident 19. The RNC stated they had a spreadsheet that resident 19…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-22 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    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 offered the Coronavirus disease 2019 (COVID-19) vaccines. Specifically, for 1 out of 5 sampled residents, no documentation was located to demonstrate how the resident accepted or refused the COVID-19 vaccination. Resident identifiers: 19. Findings included:Resident 19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include, but were not limited to, neurocognitive disorder with Lewy bodies.A review of resident 19's immunization in the medical record revealed no documentation for the current 2025/2026 COVID-19 season.On 4/22/26 at 11:09 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated they did not have the requested documentation for resident 19. The RNC stated they had a spreadsheet that resident 19 refused but no declination form was completed. The RNC stated on admission the immunization consent forms were in the admission paperwork. The RNC 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-03 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, hand hygiene was not performed when delivering lunch trays between multiple resident rooms. Findings include: On 3/31/25 at 12:40 PM through 12:47 PM, an observation of the East Wing during lunch service was completed. An observation was made of Certified Nursing Assistant (CNA) 1 who served room [ROOM NUMBER] a food tray and placed the tray on the bedside table. CNA 1 was observed to have moved the table closer to the resident then exited room. CNA 1 then went to the meal cart without performing hand hygiene and grabbed a food tray for room [ROOM NUMBER]. CNA 1 delivered the tray, set up the meal for the resident, exited the room and hand hygiene was not completed. Certified Nursing Assistant Coordinator (CNAC) was…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-03 · tag F0773 — isolated
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 19 sampled residents, the facility must obtain laboratory services only when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist. In addition, the facility must promptly notify the ordering physician of laboratory results that fall outside of clinical reference ranges. Specifically, resident's urinalysis (UA) results were not obtained from the lab and reported to the ordering physician. Resident identifier: 6. Findings include: Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with generalized muscle weakness, type II diabetes, need for assistance with personal cares, and chronic kidney disease stage 3. The medical record of resident 6 was reviewed 3/31/25 through 4/3/25. A progress note dated 1/16/25 documented, .pt [patient] co [complained of] retaining urine [sic] retention, straight Cath [catheter] performed on patient and there was 255 mls [milliliters] postvoid. PT…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-10-29 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure 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 that 3 of 12 sampled residents were free of significant medication errors. Specifically, three residents were not administered insulin at the correct time per the physician orders. Resident identifiers: 2, 4, and 10. Findings include: The facility's posted insulin administration times are: 7:00 AM, 11:30 AM, and 4:30 PM. Resident Council Notes dated 5/14/24 revealed the following. Not getting meds in a timely manner . Resident Council Notes dated 6/12/24 revealed the following. Meds still not on time Resident Council Notes dated 7/9/24 revealed the following. Meds being passed too late at [sic.] night Resident Council Notes dated 8/27/24 revealed the following. Meds not given when asked. 1. Resident 2 was admitted to the facility on [DATE] and discharged on 5/29/24 with diagnoses which included Type 1 diabetes mellitus, acute kidney failure, sepsis, encephalopathy, type 2 diabetes mellitus with foot ulcer, and depression. Review of Resident 2'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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-10-29 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined for 2 of 12 sampled residents that the facility did not ensure that the residents were free from abuse. Specifically, two residents reported that a Certified Nurse Assistant (CNA) inappropriately touched them on their genitals. Resident identifiers: 1 and 11. Findings included: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included left knee osteoarthritis, type 2 diabetes mellitus, morbid obesity, chronic pain syndrome, and venous peripheral insufficiency. The facility investigation was reviewed 10/28/24 through 10/29/24. Form 358 was submitted to the State Survey Agency on 9/16/24 at 7:55 PM. The form indicated an incident of sexual abuse was reported by the Administrator (ADM). It indicated, [CNA 2]- CNA during her shift was helping another CNA on shift help change resident [resident 1]. [Resident 1] had been engaging in small talk with [CNA 2] and then told her that a man (CNA [CNA 3]) on night shift got 'touchy' with her and…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · Dcited before2024-10-29 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined for 1 of 12 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency (SSA). Specifically, a sexual abuse allegation was reported to the SSA. Resident identifier: 11. Findings included: An untitled and undated document was provided as part of a facility abuse allegation investigation, it indicated, Resident/room #/staff member [resident 11] -105 B - What interaction have you had in the past with this staff member? - when changing me, his hand brushed across my breast. Possibly intentionally. -didn't think it was intentional so I didn't tell any [illegible hand writing] - patted on backside and stomach briefly when being changed - just weird. A few weeks ago. On 10/29/24 at 9:50 AM, 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-10-29 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined for 1 of 12 sampled residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated. Specifically, there was an allegation of abuse that was not thoroughly investigated. Resident identifier: 11. Findings included: An untitled and undated document was provided as part of a facility abuse allegation investigation, it indicated, Resident/room #/staff member [resident 11] -105 B - What interaction have you had in the past with this staff member? - when changing me, his hand brushed across my breast. Possibly intentionally. -didn't think it was intentional so I didn't tell any [illegible hand writing] - patted on backside and stomach briefly when being changed - just weird. A few weeks ago. On 10/29/24 at 9:50 AM, the Administrator (ADM) provided a document that included his interpretation of his hand writing of the interview with resident 11, it indicated, Resident [Resident 11] Statement: When CNA [Certified…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-12-21 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not 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, including Coronavirus Disease 2019 (COVID-19). Specifically, during a COVID-19 outbreak the facility staff did not dispose of their used Personal Protective Equipment (PPE) correctly, staff did not wear eye protection when entering COVID positive resident rooms, meal trays were not bagged and identified when taken from COVID positive resident rooms and a symptomatic resident was not tested promptly for COVID-19 after staff were made aware. Resident identifier: 4 & 35. Findings included: 1. On 12/20/23 at 10:21 AM, an observation was made of the Certified Nursing Assistant Coordinator (CNAC) and Certified Nursing Assistant (CNA) 3. CNAC and CNA 3 were observed to remove the garbage which held the soiled gowns and gloves from 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-21 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure 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 28 medication opportunities on 12/20/23, revealed seven medication errors which resulted in a 25% medication error rate. Specifically, for 3 out of 20 sampled residents, a resident was given an incorrect dose of an anticonvulsant, a resident received long acting insulin and corrective insulin for an elevated blood sugar late, and a resident with scheduled pain medication received them late. Resident identifier: 1, 20, 35. Findings included: 1. Resident 20 was admitted to the facility on [DATE] with diagnoses which included depression, chronic systolic heart failure and hypertension. On 12/20/23 at 7:52 AM, an observation was made of Registered Nurse (RN) 1 during morning medication administration. RN 1 was observed to prepare and administer medications to resident 20. RN 1 administered Divalproex delayed release 500 MG (milligram). Resident 20's 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-12-21 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure 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 it was determined for 4 of 20 sampled residents that the facility did not ensure that the residents were free from any significant medication errors. Specifically, a resident was given the incorrect dose of medication, a resident's insulin medication was not administered per the physician's ordered time, one residents pain medication was not administered per the physician's ordered time, and on residents anxiety medication was not administered timely causing the resident distress. Resident identifiers: 1, 20, 35, and 4. Findings included: 1. Resident 20 was admitted to the facility on [DATE] with diagnoses which included depression, chronic systolic heart failure and hypertension. On 12/20/23 at 7:52 AM, an observation was made of Registered Nurse (RN) 1 during morning medication administration. RN 1 was observed to prepare and administer medications to resident 20. RN 1 administered Divalproex delayed release 500 MG (milligram). Resident 20's Medication Administration Record…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-21 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the refrigerators and freezers were open to air. Findings include: 1. On 12/19/23 at 9:07 AM, an initial inspection was completed. In the freezer labeled Freezer 2, a box of pork sausage patties was open to air. In the refrigerator labeled Fridge 1, a container of curry paste with an expiration date of 9/11/2020 was present. Also in Fridge 1, a container of egg product had a use by date of 12/4/23. The container had been opened on 12/19/23 and an expiration date of 12/25/23 was written on the container. 2. On 12/21/23 at 8:53 AM, a second walk-through of the kitchen was conducted. The freezer labeled Freezer 2 contained a box of pork sausage patties that were open to air. The freezer labeled Freezer 1 contained a box of white dinner rolls that was open to air. The refrigerator labeled Fridge 1 the container of curry paste with an expiration date of 9/11/2020 was still present. Also in Fridge…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-21 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined, for 1 of 20 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA). Specifically, a resident had an unwitnessed fall which resulted in a fracture and the SSA was not notified. Resident Identifier: 28. Findings Included: Resident 28 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses of chronic respiratory failure, muscle weakness, acute pulmonary edema, heart failure, acute kidney failure, and cellulitis. Resident 28's medical record was reviewed on 12/20/23. On 8/25/23, a Quarterly Minimum Data Set (MDS) documented Resident 28 had a Brief Interview for Mental Status (BIMS) score of 2 which indicated resident 28 was severely cognitively impaired. Resident 28's functional…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-21 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 20 sampled residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to have evidence that all alleged violations were thoroughly investigated. Specifically, the facility did not thoroughly investigate an unwitnessed fall that resulted in a fracture. Resident Identifier: 28. Findings Included: Resident 28 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses of chronic respiratory failure, muscle weakness, acute pulmonary edema, heart failure, acute kidney failure, and cellulitis. Resident 28's medical record was reviewed on 12/20/23. On 8/25/23, a Quarterly Minimum Data Set (MDS) documented Resident 28 had a Brief Interview for Mental Status (BIMS) score of 2 which indicated resident 28 was severely cognitively impaired. Resident 28's functional status was documented as a two-person physical assist. On 10/12/23 at 5:58 PM, a health status 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-21 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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 it was determined, for 2 of 20 sample residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice. Specifically, facility staff were not changing the oxygen tubing. Resident identifier: 1, 18. Findings included: 1. Resident 1 was admitted to the facility on [DATE] with diagnosis which included chronic obstructive pulmonary disease, unspecified dementia, and muscle weakness. On 12/19/23 at 10:10 AM, an interview was conducted with resident 1. Resident 1 stated that she could not remember when her oxygen tubing was last changed, but that it was suppose to be changed frequently. Resident 1's oxygen tubing was observed with a date of 12/3/23 written on tape which was wrapped around the oxygen tubing. On 12/20/23 resident 1's medical record was reviewed. A physicians order documented an oxygen maintenance order: Change oxygen tubing and storage bag weekly. Label…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-08-24 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined that the facility did not employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. Specifically, the facility did not employ a qualified dietary manager that possesses one or more of the following credentials: Certified Dietary Manager, Certified Food Service Manager, a Food Service Management Certificate, 2 or more years of experience in a nursing facility setting as a food service director and has completed a course of study in food safety and management, or an associates degree or higher with coursework in food service, hospitality, or restaurant management. Findings Include: On 8/22/23 at 10:07 AM, an interview was conducted with Dietary Manager (DM) 2. DM 2 had started working on the facility 8/16/23 and had been hired to replace the previous Dietary Manager, DM 1. DM 2 stated that he had worked as the lead chef at his previous facility. DM 2 stated that he was still completing the company dietary manager training and that he had until the end…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-24 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined that the facility failed to ensure that the Quality Assessment and Assurance (QAA) Committee developed and implemented systematic analysis and action to ensure that improvements were effective and sustained to prevent adverse events. Specifically, the facility did not implement effective plans of action to correct identified quality deficiencies which resulted in the continuation of residents not receiving appropriately prepared food according to their assessment for 4 residents that were found to have occurred at an Immediate Jeopardy (IJ) Level. Resident identifiers: 1, 5, 6, and 14. Findings include: 1. Based on observation, interview, and record review, it was determined that the facility failed to ensure that 4 of 14 sampled residents received appropriately prepared food according to their assessment. Specifically, a resident received and partially consumed a meal that had not been mechanically altered per the physician orders which resulted in the resident choking on the food and requiring emergency medical…

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

    Administration Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$15,025 in federal fines across 1 penalty.

  • $15,025 — penalty dated 2023-08-24

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to BEAVER VALLEY HOSPITAL — 5 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 →

RatingThis homeChain avg
Overall 3 of 52.2+0.8 vs chain
Health inspection 2 of 51.8+0.2 vs chain
Staffing 2 of 51.6+0.4 vs chain
Quality measures 5 of 54.6+0.4 vs chain
The other 4 homes this chain runs (chain average 2.2★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
LANGFORD, SCOTTIndividualCORPORATE OFFICERsince 11/01/2020
ALPINE MEADOW REHABILITATION AND NURSINGOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/22/2025
COTTONWOOD HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/16/2025
MARCHANT, BRYANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/03/2025
MYERS, WALTERIndividualOPERATIONAL/MANAGERIAL CONTROLsince 02/10/2016
STUBBS, RACHAELIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/03/2025
BARKER, BRADLEYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 08/22/2025
BARKER, SHERIIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 08/22/2025
FEY, DANIELIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 08/22/2025
FEY, ETHANIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 08/22/2025
MYERS, KATIEIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 08/22/2025
SWAIN, HOLLYIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/01/2026
SWAIN, JAREDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 04/01/2026
BEAVER VALLEY HOSPITALOrganizationADP OF THE SNFsince 07/19/2016

CMS files one row per role, so the 18 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$5.0M
Net patient revenuemost recent cost report
+15.6%
Operating marginrevenue minus expenses
$1.5M
Related-party expense35% of expenses

This home reported $1.5M paid to related parties — landlords or management companies under common ownership — equal to about 35% 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 2023. 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

$295per resident / day
operating cost
$8,979per month
≈ monthly operating cost
$350per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). 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

Paying with Medicaid

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.

Typical monthly cost in Utah
$8,669/mo
Nursing home (semi-private)
$10,646/mo
Nursing home (private)
$5,475/mo
Assisted living

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 465191. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-22, 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.

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