Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% better than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 3, 2025
Visit Reason
The inspection was conducted based on a complaint investigation regarding neglect of a resident who was left in a wet brief for an extended period, resulting in skin injury.
Complaint Details
The complaint was substantiated. The investigation found that Certified Nursing Assistant 4 failed to perform required two-hour checks and left resident 9 in a wet brief for approximately eight hours, causing skin breakdown. The facility suspended and terminated the employee and initiated staff education and increased monitoring.
Findings
The facility failed to ensure residents' rights to be free from neglect, as evidenced by one resident left in a wet brief for about eight hours, resulting in rash and excoriation. The responsible Certified Nursing Assistant was suspended and later terminated following the investigation.
Deficiencies (1)
Failure to protect residents from neglect, specifically leaving a resident in a wet brief for an extended period causing skin injury.
Report Facts
Residents sampled: 13
Hours resident left in wet brief: 8
Date of incident: Mar 13, 2025
Date of survey: Dec 3, 2025
Psychosocial checks ordered: 72
Nurse checks frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 4 | Certified Nursing Assistant | Employee responsible for neglect, suspended and terminated after investigation |
| Certified Nursing Assistant 5 | Certified Nursing Assistant | Discovered resident in wet brief and notified nurse |
| Registered Nurse 1 | Registered Nurse | Assessed resident, confirmed condition, and intervened during incident |
| Regional Nurse Consultant | Regional Nurse Consultant | Ordered psychosocial and nurse checks following incident |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 16, 2024
Visit Reason
The inspection was conducted in response to complaints and allegations of inadequate facility environment and a serious abuse incident involving a resident and a staff member.
Complaint Details
The complaint investigation revealed that on 4/8/24, a resident with dementia was missing for approximately 20 minutes and was found in a locked therapy gym area with a Physical Therapy Assistant (PTA). The resident alleged sexual contact with the PTA, who was placed on administrative leave pending investigation. The facility failed to prevent the abuse and maintain proper supervision. Immediate Jeopardy was declared and abated on 4/11/24. Multiple interviews with staff and residents confirmed the incident and the facility's inadequate response.
Findings
The facility was found to have persistent strong urine and body odors throughout multiple hallways and rooms, indicating failure to maintain a clean and comfortable environment. Additionally, an Immediate Jeopardy was identified due to a sexual abuse allegation involving a Physical Therapy Assistant and a resident with dementia, including failure to prevent abuse and inadequate supervision. The facility took immediate corrective actions including staff separation, police notification, resident assessment, and staff education.
Deficiencies (2)
Failure to provide a clean, comfortable, homelike environment due to persistent strong urine and body odors throughout the facility.
Failure to protect residents from abuse, neglect, and exploitation, specifically a sexual abuse incident involving a resident and a staff member, resulting in Immediate Jeopardy.
Report Facts
Residents sampled: 27
Residents affected: 1
Deficiency citations: 2
BIMS score: 14
Time missing: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PTA 1 | Physical Therapy Assistant | Alleged perpetrator in sexual abuse incident |
| RN 1 | Registered Nurse | Conducted resident assessment and reported incident |
| CNA 1 | Certified Nursing Assistant | Witnessed resident condition and reported abuse details |
| CNA 2 | Certified Nursing Assistant | Witnessed resident condition and reported abuse details |
| TC | Therapy Coordinator | Provided information on PTA work hours and documentation |
| Administrator | Facility Administrator | Received abuse report, coordinated investigation and abatement plan |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Apr 16, 2024
Visit Reason
The inspection was conducted due to complaints and allegations including odor issues, abuse and neglect allegations, and concerns about resident care and food quality.
Complaint Details
The complaint investigation included allegations of strong odors in the facility, sexual abuse of a resident by a staff member resulting in immediate jeopardy, failure to provide adequate care plans and supervision leading to falls and injuries, and poor food quality and snack availability.
Findings
The facility was found to have multiple deficiencies including failure to maintain a clean and odor-free environment, immediate jeopardy related to abuse and neglect of a resident by a staff member, failure to develop and implement comprehensive care plans, inadequate supervision and accident prevention, poor food quality and temperature control, and failure to provide suitable snacks and alternative meals.
Deficiencies (7)
Facility did not provide a clean, comfortable, homelike environment due to strong urine and body odors throughout the facility.
Failure to protect residents from abuse, neglect, and exploitation; Immediate Jeopardy identified due to sexual abuse allegation involving a staff member and a resident.
Facility did not develop and implement comprehensive person-centered care plans with measurable objectives and timeframes, resulting in multiple falls and injuries for a resident.
Resident environment was not free from accident hazards; inadequate supervision and lack of assistance devices contributed to multiple falls.
Facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature; test trays were bland and some food items were dry or tough.
Facility failed to provide suitable and nourishing alternative meals and snacks for residents wanting to eat at non-traditional times; snacks were limited mostly to saltine crackers.
Dish machine washing temperature was below manufacturer required temperature and sanitizer strips were not available to test sanitizer solution.
Report Facts
Residents sampled: 27
Resident Identifier: 31
Resident Identifier: 9
Resident Identifiers: Array
Resident Identifiers: Array
Dish machine wash temperature: 110
Dish machine rinse temperature: 120
Dish machine wash temperature: 115
Dish machine rinse temperature: 119
Dish machine sanitizer level: 100
Dish machine wash temperature: 100
Dish machine rinse temperature: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PTA 1 | Physical Therapy Assistant | Alleged perpetrator in sexual abuse allegation; was placed on administrative leave and not connected to facility through DACS |
| RN 1 | Registered Nurse | Conducted assessment of resident 31 after abuse allegation; documented findings |
| CNA 1 | Certified Nursing Assistant | Witnessed and reported sexual abuse allegation involving resident 31 |
| CNA 2 | Certified Nursing Assistant | Witnessed and reported sexual abuse allegation involving resident 31 |
| LPN 1 | Licensed Practical Nurse | Reported on resident 9's falls and care plan interventions |
| DON | Director of Nursing | Interviewed regarding resident care plans and abuse investigation |
| DM | Dietary Manager | Interviewed regarding food quality and dish machine issues |
| Vendor Consultant | Consulted on dietary services and dish machine temperatures |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jun 27, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, medication management, and data submission for a nursing home facility.
Findings
The facility failed to complete comprehensive resident assessments within required timeframes, did not encode and transmit discharge Minimum Data Set (MDS) assessments timely, inaccurately coded a resident's discharge status, and did not ensure residents' drug regimens were free from unnecessary drugs, specifically holding hypertensive medications without physician ordered parameters.
Deficiencies (6)
Facility did not conduct comprehensive assessments of residents in accordance with specified timeframes; 3 out of 31 sampled residents lacked annual MDS assessments completed on time.
Facility did not comprehensively assess a resident within 14 days after a significant change in condition; 1 out of 31 sampled residents lacked a significant change MDS assessment.
Facility did not assess residents using the quarterly review instrument at least every 3 months; 13 out of 31 sampled residents had overdue quarterly MDS assessments.
Facility did not encode discharge MDS assessment data within 7 days after completion for 3 out of 31 sampled residents.
Facility assessments did not accurately reflect resident status; 1 out of 31 sampled residents had discharge MDS assessment incorrectly coded as discharged to hospital instead of home.
Facility did not ensure residents' drug regimens were free from unnecessary drugs; a resident's hypertensive medications were held without physician ordered parameters.
Report Facts
Sampled residents: 31
Residents with overdue annual MDS assessments: 3
Residents with overdue significant change MDS assessment: 1
Residents with overdue quarterly MDS assessments: 13
Days late for quarterly MDS assessments: 21
Days late for quarterly MDS assessments: 47
Days late for quarterly MDS assessments: 57
Days late for quarterly MDS assessments: 80
Days late for quarterly MDS assessments: 83
Days late for quarterly MDS assessments: 94
Days late for quarterly MDS assessments: 95
Days late for quarterly MDS assessments: 101
Discharge MDS assessments not completed: 3
Blood pressure readings when hydrochlorothiazide was held: 8
Blood pressure readings when losartan potassium was held: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Responsible for completing and finalizing MDS assessments; acknowledged overdue assessments and incorrect coding |
| Director of Nursing | DON | Confirmed resident discharge status; stated no standing orders for blood pressure medications; discussed nursing judgment in holding medications |
| Social Services Director | SSD | Confirmed resident discharge to home, not hospital |
| Registered Nurse 1 | RN | Reported holding medication without physician parameters based on nursing judgment; would notify MD if SBP < 100 |
| Registered Nurse 2 | RN | Reported no standing orders for blood pressure; would ask MD or NP for parameters if needed |
Inspection Report
Deficiencies: 5
Date: Feb 20, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident notification of transfers or discharges, pharmaceutical services, medication administration, narcotic reconciliation, unnecessary drug use, and laboratory services.
Findings
The facility was found deficient in timely notification to the Ombudsman for resident transfers to hospital, pharmaceutical services including medication availability and accurate administration, narcotic medication reconciliation discrepancies, failure to ensure residents' drug regimens were free from unnecessary drugs, and failure to provide timely and complete laboratory services and documentation.
Deficiencies (5)
Failure to notify the Office of the State Long-Term Care Ombudsman of resident transfers or discharges to hospital for 2 of 24 sampled residents.
Failure to provide pharmaceutical services ensuring accurate acquiring, receiving, dispensing, and administering of drugs for 6 of 24 sampled residents due to medications not being available for administration.
Discrepancies between Medication Administration Records and Controlled Substance Logs for narcotic medications for 1 resident, indicating inadequate narcotic reconciliation.
Failure to ensure a resident's drug regimen was free from unnecessary drugs, including lack of timely monitoring of anticoagulation therapy leading to hospitalization.
Failure to provide timely, quality laboratory services/tests and failure to keep complete, dated laboratory records in residents' records for multiple residents.
Report Facts
Sample residents: 24
Residents affected - Ombudsman notification: 2
Residents affected - Pharmaceutical services: 6
Residents affected - Narcotic reconciliation: 1
Residents affected - Unnecessary drugs: 1
Residents affected - Laboratory services: 4
INR value: 30.2
Medication doses: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding Ombudsman notification and facility processes | |
| Director of Nursing (DON) | Interviewed regarding medication availability, narcotic reconciliation, and corrective actions | |
| Licensed Practical Nurse (LPN) 1 | Interviewed regarding narcotic medication administration and reconciliation | |
| Licensed Practical Nurse (LPN) 2 | Interviewed regarding lab order entry and documentation | |
| Consultant Pharmacist | Interviewed regarding narcotic audits and medication administration | |
| Assistant Director of Nursing (ADON) | Interviewed regarding laboratory result documentation and retrieval |
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