Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% better than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 3, 2025
Visit Reason
The inspection was conducted due to 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 the resident in urine for about eight hours, resulting in skin damage. The employee was suspended and later terminated.
Findings
The facility failed to ensure a resident's right to be free from neglect, as one resident was found with a rash and excoriation after being left in a wet brief for about eight hours. The investigation confirmed staff negligence and resulted in termination of the responsible employee.
Deficiencies (1)
F 0600: Protect each resident from all types of abuse including neglect. A resident was left in a wet brief for an extended period causing rash and excoriation to the groin area.
Report Facts
Residents sampled: 13
Resident affected: 1
Duration resident left in wet brief: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 4 | Certified Nursing Assistant | Named as responsible for neglect and subsequent termination |
| Registered Nurse 1 | Registered Nurse | Assessed resident condition and intervened during incident |
| Certified Nursing Assistant 5 | Certified Nursing Assistant | Discovered resident in neglected state and reported to nurse |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Apr 16, 2024
Visit Reason
The inspection was conducted due to complaints and allegations including failure to maintain a clean environment, abuse and neglect allegations involving a resident and staff member, and concerns about resident care and food quality.
Complaint Details
The complaint investigation was triggered by allegations of abuse and neglect involving a resident who was missing and found in a locked therapy room with a staff member. The resident reported sexual misconduct by the staff member. Immediate jeopardy was identified and abated on the same day. Additional complaints included poor environmental conditions, inadequate care planning, and food service issues.
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, inadequate care planning and fall prevention for a resident, poor food quality and unsafe food temperatures, and inadequate snack availability for residents.
Deficiencies (8)
F 0584: The facility failed to provide a clean, comfortable, homelike environment, with strong urine and body odors observed in multiple hallways and dining areas.
F 0600: The facility failed to protect a resident from abuse, neglect, and exploitation, resulting in immediate jeopardy due to a staff member engaging in sexual actions with a cognitively impaired resident.
F 0607: The facility did not develop and implement policies and procedures to prevent abuse, neglect, and exploitation, as a staff member was not connected to the facility through the required clearance system.
F 0656: The facility failed to develop and implement a comprehensive care plan with measurable objectives and timeframes for a resident, resulting in multiple falls, a skin tear, and hip pain.
F 0689: The facility did not ensure the resident environment was free from accident hazards and did not provide adequate supervision or assistance devices to prevent falls for a resident.
F 0804: The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature, with bland pureed foods, dry cake, and low food temperatures observed.
F 0809: The facility failed to provide suitable and nourishing alternate meals and snacks for residents wanting to eat at non-traditional times, offering mostly saltine crackers as snacks.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards; dish machine washing temperatures were below manufacturer requirements and sanitizer strips were unavailable.
Report Facts
Residents sampled: 27
Dish machine wash temperature: 100
Dish machine rinse temperature: 115
Dish machine sanitizer PPM: 100
Resident BIMS score: 14
Resident falls: 3
Food temperatures: 116.5
Food temperatures: 120.5
Food temperatures: 119.4
Food temperatures: 114.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PTA 1 | Physical Therapy Assistant | Named as alleged perpetrator in sexual abuse of resident 31; placed on administrative leave and not allowed to return |
| RN 1 | Registered Nurse | Conducted assessment of resident 31 after abuse allegation and reported findings |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding resident 9's falls and care plan |
| CNA 1 | Certified Nursing Assistant | Interviewed regarding resident 31 and abuse incident |
| CNA 2 | Certified Nursing Assistant | Interviewed regarding resident 31 and abuse incident |
| Dietary Manager | Dietary Manager | Interviewed regarding food quality and dish machine issues |
| Vendor Consultant | Vendor Consultant | Consulted on dietary services and dish machine operations |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 16, 2024
Visit Reason
The inspection was conducted due to a complaint investigation triggered by allegations of abuse and neglect involving a resident and a staff member, as well as concerns about odors and environmental conditions in the facility.
Complaint Details
The complaint investigation was substantiated with Immediate Jeopardy identified on 4/11/24 due to failure to protect resident 31 from sexual abuse by a Physical Therapy Assistant. The resident was missing for about 20 minutes in a locked therapy gym area where the alleged abuse occurred. The facility responded by separating the resident and staff member, notifying authorities, and implementing corrective actions including staff education, removal of locks, and monitoring. Resident 31 was cognitively impaired with dementia and required supervision. Multiple staff interviews confirmed the incident and the resident's statements. The staff member was placed on administrative leave and subsequently terminated.
Findings
The facility was found to have a persistent strong urine and body odor throughout multiple hallways and rooms. An Immediate Jeopardy was identified related to failure to protect a resident from sexual abuse by a staff member. The resident was missing for a period of time in a locked therapy gym area where the alleged abuse occurred. The facility took immediate actions to remove the staff member and implemented systemic changes. The resident was assessed with no injuries noted. The investigation included multiple staff and resident interviews and review of medical records.
Deficiencies (2)
F 0584: The facility failed to provide a clean, comfortable, homelike environment as strong urine and body odors were present throughout hallways and dining areas.
F 0600: The facility failed to protect a resident from abuse, resulting in Immediate Jeopardy due to sexual abuse allegations involving a staff member and a resident with dementia.
Report Facts
Residents sampled: 27
Resident identifier: 31
BIMS score: 14
Time resident missing: 20
Date survey completed: Apr 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physical Therapy Assistant | Alleged perpetrator in sexual abuse incident involving resident 31; placed on administrative leave and terminated | |
| RN 1 | Registered Nurse | Conducted full body assessment of resident 31 and involved in investigation |
| CNA 1 | Certified Nursing Assistant | Witnessed resident 31's condition and statements related to abuse |
| CNA 2 | Certified Nursing Assistant | Witnessed resident 31's condition and statements related to abuse |
| Student Nurse | First staff to find resident 31 after missing | |
| TC | Therapy Coordinator | Provided information about PTA 1's work hours and documentation |
| Administrator | Facility Administrator | Received Immediate Jeopardy notice and coordinated response |
| DON | Director of Nursing | Involved in investigation and interviews |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jun 27, 2022
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident assessments, including comprehensive, significant change, quarterly, and discharge Minimum Data Set (MDS) assessments, as part of the facility's annual survey.
Findings
The facility failed to complete comprehensive annual assessments, significant change assessments, quarterly assessments, and discharge assessments within required timeframes for multiple residents. Additionally, one resident's discharge assessment was inaccurately coded, and one resident's drug regimen was not managed with physician-ordered parameters.
Deficiencies (6)
F0636: The facility did not complete comprehensive annual Minimum Data Set (MDS) assessments timely for 3 of 31 sampled residents.
F0637: The facility did not complete significant change MDS assessments within 14 days for 1 of 31 sampled residents after a significant change in condition.
F0638: The facility did not complete quarterly MDS assessments at least every 3 months or within 14 days after the assessment reference date for 13 of 31 sampled residents.
F0640: The facility did not encode and transmit discharge MDS assessments within 7 days for 3 of 31 sampled residents.
F0641: A resident's discharge MDS assessment was inaccurately coded as discharged to a hospital when the resident was discharged home.
F0757: The facility did not ensure a resident's drug regimen was free from unnecessary drugs; blood pressure medications were held without physician ordered parameters and inconsistent notification of the medical director occurred.
Report Facts
Sampled residents: 31
Residents with incomplete annual assessments: 3
Residents with incomplete significant change assessments: 1
Residents with incomplete quarterly assessments: 13
Residents with incomplete discharge assessments: 3
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
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Interviewed regarding MDS assessment process and acknowledged overdue assessments | |
| Registered Nurse 1 | RN | Interviewed about medication administration and physician ordered parameters |
| Registered Nurse 2 | RN | Interviewed about physician ordered parameters and standing orders |
| Director of Nursing | Interviewed about medication administration policies and nurse judgment | |
| Social Services Director | Interviewed regarding resident discharge destination |
Inspection Report
Routine
Deficiencies: 5
Date: Feb 20, 2020
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to notify the Ombudsman of resident transfers, pharmaceutical service deficiencies with unavailable medications, narcotic medication administration discrepancies, failure to ensure drug regimens were free from unnecessary drugs, and inadequate laboratory services and record keeping.
Deficiencies (5)
F 0623: The facility failed to notify the State Long-Term Care Ombudsman of resident transfers or discharges for 2 of 24 sampled residents.
F 0755: The facility did not provide pharmaceutical services ensuring accurate acquiring, receiving, dispensing, and administering of drugs; six residents lacked medications available for administration.
F 0757: The facility failed to ensure residents' drug regimens were free from unnecessary drugs; one resident did not receive timely monitoring of anticoagulation therapy and was hospitalized.
F 0770: The facility failed to provide timely, quality laboratory services; two residents did not have ordered labs obtained.
F 0775: The facility failed to keep complete, dated laboratory records in residents' medical records; four residents lacked lab results in their records.
Report Facts
Sample residents: 24
Residents affected: 2
Residents affected: 6
Residents affected: 1
Residents affected: 2
Residents affected: 4
INR lab result: 30.2
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