Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadow Peak Rehabilitation during CMS and state inspections, most recent first.
Incomplete lidocaine orders and improper narcotic handling were observed. Two residents had lidocaine patch orders that lacked clear dosage and schedule details, and the MARs did not consistently match the ordered use or document patch removal times. Staff were also observed taping clonazepam, oxycodone, and hydrocodone-acetaminophen back into medication cards, and RN and DON interviews confirmed this was not appropriate.
Food Quality and Temperature Concerns: Multiple residents reported that meals were cold, bland, poorly presented, or otherwise unappetizing, and resident council notes documented repeated complaints about cold food, late service, soggy bread, and canned fruit. Surveyors also sampled a lunch tray and found the green beans overcooked and mushy, the alfredo sauce flavorless, and the chicken gristly and difficult to chew.
A resident with hemiplegia, depression, and anxiety disorder was started on buspirone for anxiety, but the DON could not show that the resident’s representative was informed in advance of the risks and benefits or alternatives before the medication was initiated. No documentation was provided to confirm that the representative was notified.
A resident with Parkinson's disease and a history of TIA/CVA had coffee-ground emesis and severe hypoxia, was sent to the hospital by ambulance after the on-call provider ordered transfer, and family and nurse management were notified. The chart included a note about the change in condition and a later note confirming hospital admission, but it did not document what records were sent with the resident; staff said they normally send the face sheet, med list, treatments, POLST, and related paperwork and document the transfer in a progress note.
Improper one-person Hoyer lift transfers: A resident with brain tumor, altered mental status, repeated falls, and hospice services required a Hoyer lift and was documented as a 2-person assist. On two observations, a hospice aide transferred the resident alone while closing the door, and the aide stated she usually got the resident out of bed on her own. CNAs, the DON, and the ADM confirmed that two staff members should be present for Hoyer transfers, including hospice staff.
Failure to provide bowel and bladder retraining for a resident with bowel and bladder incontinence. A resident with hemiplegia after CVA was documented as always incontinent, with no attempted toileting program and no current toileting program in place. The care plan addressed incontinence and dependence for toileting and transfers, while an LPN and CNA stated the resident was alert, able to communicate needs, and could alert staff before needing toileting or brief changes. The DON was unsure whether retraining had been used, and no documentation showed bowel and bladder retraining was provided.
A resident with ESRD and dependence on renal dialysis did not have complete dialysis communication forms, with missing vital signs, weights, and AV fistula/access site assessments before transport and after return from dialysis on multiple occasions. The record also lacked documentation of post-dialysis AV fistula checks and vital signs on several returns, despite the care plan and facility policy calling for monitoring of vital signs and access site condition, including bruit and thrill checks.
Nurse staff posting was not displayed in a prominent area readily accessible to residents, staff, and visitors, and the resident census was not posted daily. During observation, no posting was seen from the entrance through the main hallways, and the DON later showed the surveyor a posting in a cubby next to staff offices that did not include the resident census. The DON stated that family and residents go to the nearby office for meetings with staff and knew where to find it.
A resident with COPD, anxiety disorder, bipolar disorder, mood disorder, and tremors received excessive Depakote doses after an order was entered incorrectly as 2000 mg TID instead of the intended 500 mg TID. The MAR showed the resident received one 2000 mg dose and two days of 6000 mg doses, and the system-generated warning about the dose being above the usual regimen and maximum single dose was not acted on.
Two open insulin pens were found in a med cart without open dates, and an inhaler was given to a resident even though it had no resident ID or open date. RN stated the pens should have been dated and labeled, and the DON stated meds should already have a prescription label and should not be given if staff did not know who they belonged to.
The facility failed to document an annual review of its IPCP. The Infection Prevention and Control Policy stated the plan would be reviewed annually and updated as needed, but when the DON was interviewed, documentation showing the last review was requested and not provided.
Missing Staff COVID-19 Vaccine Documentation and Policy: The facility failed to develop and implement policies and procedures for staff COVID-19 vaccination and failed to maintain required documentation. Record review showed no documentation that a RN, CNA, LPN, and the Dietary Manager were offered the vaccine, and the DON stated staff were offered the vaccine at annual flu/COVID clinics but it was not documented. No policy was provided addressing the required education, offer, or NHSN vaccination status elements.
A resident with an ADL self-care deficit, requiring substantial assistance for bathing, was not offered a shower for 15 days. The DON reported that showers are to be offered twice weekly and refusals documented, but staff failed to document refusals or provided showers, resulting in a lack of services consistent with the resident's needs and choices.
A resident with severe cognitive impairment and a history of falls was left unattended in a shower by a CNA, resulting in a fall that caused a head laceration and pelvic fracture. The resident required extensive assistance for mobility and transfers, but was left alone in a shower chair without sides, leading to the accident. Staff interviews revealed inconsistencies in understanding the resident's care needs, contributing to the incident.
A resident with multiple health conditions was prescribed Amlodipine with specific blood pressure parameters. However, the facility failed to monitor the resident's blood pressure consistently before administering the medication, as required by the physician's order. Staff interviews revealed confusion about documentation practices, and the DON admitted that the monitoring requirement was mistakenly left on the order.
The facility failed to comply with regulations for PRN psychotropic medications, as two residents had orders for Trazodone not limited to 14 days without documented rationale. One resident was on psychotropic medications without appropriate diagnoses, and another was prescribed Quetiapine without documented behaviors. Interviews with the DON and ADON indicated a goal for 14-day PRN limits, but this was not consistently applied.
A resident with a complex medical history had additional lab tests conducted without a physician's order after completing antibiotic therapy. The facility misinterpreted hospital discharge instructions, leading to unauthorized lab tests being performed until the resident's follow-up with an infectious disease doctor.
Incomplete lidocaine orders and improper handling of narcotic medications
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of each resident because two residents had lidocaine orders that were incomplete and did not match the medication administration record. Resident 49 was admitted with diagnoses including a nondisplaced fracture of the right clavicle, cervical spondylosis, and multiple fractures of the ribs and left humerus. A physician order dated 4/7/26 directed lidocaine external patch application twice daily for pain, but the MAR documented lidocaine patches of an unknown dose with inconsistent placement and removal documentation, including entries with no recorded removal time. Resident 84 was admitted with diagnoses including unstable burst fracture of L1 and T11-T12, thoracolumbar fusion, osteoarthritis, idiopathic peripheral autonomic neuropathy, ankylosing spondylitis of the lumbar region, and arthrodesis status. A therapeutic interchange document dated 4/28/26 specified lidocaine 4% patches, one patch once daily with 12 hours on and 12 hours off, while a physician order dated the same day directed lidocaine external patch application twice daily for pain. The MAR documented lidocaine patches of an unknown dose with application and removal times that did not align with the documented interchange instructions, and RN 1 and the DON stated the order was incomplete because it lacked dosage, a 12-hour on/off schedule, and documentation of patch placement location. During medication cart observations, staff were seen taping narcotic medications back into multi-dose medication cards. Clonazepam, oxycodone, and hydrocodone-acetaminophen cards had pockets opened and reclosed with tape, with tablets observed in some pockets. RN 2 stated narcotics were not supposed to be taped back into medication cards and should be wasted with another nurse, RN 3 stated staff taped the cards when only part of a pill was needed, and the DON stated it was not appropriate to tape medications back into the cards and that they should be wasted with another nurse.
Food Quality and Temperature Concerns
Penalty
Summary
The facility did not ensure that residents received food and drink that were palatable, attractive, and at a safe and appetizing temperature. Multiple residents reported concerns about the quality of meals, including food that was cold, lacked flavor, had poor presentation, had inconsistent portions, or was difficult to identify. One resident stated the food was sometimes good and sometimes marginal, another said the taste could be better and dinner tended to be worse than other meals, and another described the food as horrible and said it was worse than a prior feeding tube. A resident also reported that the drinks had black specks in them, and another said the food had no flavor and was cold. Resident council notes from 2025 and 2026 documented repeated complaints about cold food, late food service, soggy bread from vegetable juices, large portions, and a desire for fresh fruit instead of canned fruit. During survey observation, a test tray from lunch consisted of chicken alfredo pasta with green beans, and surveyors found the green beans overcooked, mushy, and unseasoned, the alfredo sauce had no flavor, and the chicken was gristly and difficult to chew. The Dietary Manager stated residents could bring concerns to aides, nurses, or directly to her, and the Registered Dietitian stated she would pass resident food complaints to the dietary manager.
Failure to Inform Representative Before Starting Psychotropic Medication
Penalty
Summary
Resident 91, who was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, depression, and anxiety disorder, had a physician order dated 4/29/26 for buspirone 10 mg by mouth three times daily for anxiety disorder. During an interview on 5/11/26, the DON was unable to provide information showing that the resident’s representative was notified in advance of the risks and benefits or alternatives before buspirone was started for anxiety. No documentation was provided to show that the representative was informed of the risks and benefits or alternatives before the medication was initiated.
Missing Transfer Documentation for Hospital Discharge
Penalty
Summary
The facility did not ensure that a transfer or discharge was documented in the resident's medical record and that appropriate information was communicated to the receiving health care institution or provider for one resident. Resident 80, who had diagnoses including Parkinson's disease without dyskinesia and a personal history of transient ischemic attack and cerebral infarction without residual deficits, vomited coffee-ground colored emesis at about 5:25 AM and was found with oxygen saturation of 75% on room air. Nursing staff applied oxygen, the resident's saturation improved to 92% on 5 liters, and the on-call provider gave a verbal order to send the resident to the hospital for further evaluation. The resident agreed to be sent, ambulance services transported the resident to the hospital, and nurse management and family were notified. The medical record contained a nursing progress note describing the change in condition and transfer, and a later note confirmed the resident had been admitted to the hospital. However, there was no progress note, assessment, discharge summary, or uploaded document stating what documentation was sent with the resident when transferred. During interviews, RN 1 stated that when a resident is discharged to the hospital, staff send the profile page, order summary, medication list, and POLST, and document the event in a progress note. LPN 1 stated that staff send the face sheet, medication list, treatments received, POLST, and a copy of the face sheet, and usually document the discharge in a progress note. The DON stated that staff should send a face sheet, POLST, and medication list with the patient and that this should be documented in the medical record.
Improper one-person Hoyer lift transfers
Penalty
Summary
The facility did not ensure that the resident environment remained as free of accident hazards as possible and did not ensure adequate supervision and assistance devices to prevent accidents for a dependent resident who required a Hoyer lift for transfers. Resident 30 had diagnoses including malignant neoplasm of the parietal lobe, major depressive disorder, repeated falls, dependence on supplemental oxygen, age-related osteoporosis, altered mental status, and encephalopathy, and was admitted to hospice services. The resident’s record documented that a Hoyer lift was required for transfers and that hospice aide services were provided every morning, including weekends. On two separate observations, a hospice aide was seen taking a Hoyer lift into Resident 30’s room and closing the door while no other staff were present. About 10 minutes later, the aide exited the room and Resident 30 was observed sitting in her wheelchair with the bed made. The aide stated she was the only hospice aide who came to see the resident and that she usually got the resident out of bed on her own. Interviews with two CNAs, the DON, and the Administrator confirmed that Resident 30 was a 2-person assist for Hoyer transfers and that two staff members should be present when using the lift, including for contracted or hospice staff.
Failure to Provide Bowel and Bladder Retraining for an Incontinent Resident
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of both bowel and bladder received appropriate treatment and services to restore continence to the extent possible and to restore as much normal bowel function as possible. Resident 47 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. A Minimum Data Set assessment indicated the resident was always incontinent of bowel and bladder, had not had an attempted trial of a toileting program on admission, reentry, or since urinary incontinence was noted, and was not currently on a toileting program to manage bowel continence. The care plan identified bladder and bowel incontinence related to impaired mobility and included interventions to check every 2 hours, provide perineal care, and change clothing as needed after incontinence episodes. Another care plan noted the resident had an ADL self-care performance deficit related to a history of CVA with hemiplegia and weakness, was usually dependent with toileting, and usually dependent for transfers requiring a 2-person assist. During interviews, an LPN stated the resident had previously been able to get to the wheelchair to use the bathroom but was now incontinent and dependent on 2 people to help her stand, and that she had no medical reason to be incontinent and was alert and oriented and able to convey her needs. A CNA stated the resident was incontinent but able to communicate her needs and could alert staff before needing to use the restroom and when she required a brief change. The DON stated she was not sure whether the resident had been on a bowel and bladder retraining program. No documentation was provided showing that the resident received bowel and bladder retraining.
Incomplete Dialysis Monitoring and Documentation
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for Resident 49, who was admitted with diagnoses of end stage renal disease and dependence on renal dialysis. Record review showed multiple Renal Dialysis Communication Forms were incomplete, including missing vital signs, weights, and access site assessments before the resident left the facility for dialysis on several dates. One form was also missing a post-dialysis weight, and communication with the dialysis center was not complete as documented in the record. The medical record also showed no documentation of AV fistula assessment before leaving the facility for dialysis on 4/10/26, and no documentation of AV fistula assessment when the resident returned from dialysis on multiple dates. In addition, there were no vital signs obtained when the resident returned from dialysis on several dates. The care plan identified the resident’s need for hemodialysis and included monitoring vital signs, access site condition, and signs of complications. Staff interviews indicated differing understandings of the required post-dialysis assessment process, while the facility policy stated nursing staff would monitor the port site for bleeding, infection, and bruits and thrills.
Nurse Staff Posting Not Readily Accessible and Missing Resident Census
Penalty
Summary
The facility failed to post the nurse staff posting data in a prominent place readily accessible to residents, staff, and visitors and failed to post the resident census on a daily basis. During observation on 5/7/26 at 3:25 PM, no nurse staff posting was seen from the entrance of the facility through the main hallways of the resident rooms and nursing stations. The Director of Nursing was then located and escorted the surveyor to a cubby on the left side of the southeast rehabilitation hallway next to staff offices, where the nurse staff posting was found. The posting did not include the resident census. During a concurrent interview, the DON stated that family and residents go to the office next to the nurse staff posting for meetings with staff, so they knew where it was located.
Excessive Depakote Dosing Due to Medication Order Entry Error
Penalty
Summary
A resident with diagnoses including COPD, anxiety disorder, bipolar disorder, mood disorder, and tremors received excessive Depakote doses on multiple occasions. The resident was initially ordered Depakote 500 mg, 3 tablets by mouth three times a day, and that order was discontinued the same day. A follow-up order changed the dose to 500 mg, 4 tablets by mouth three times a day. The September 2025 MAR showed the resident received 2000 mg of Depakote once and then 6000 mg on two subsequent days, when the resident should have received 500 mg on the first day and 1500 mg on each of the next two days. The record also showed that the computer-generated warning identified the ordered dose as exceeding the usual dosing regimen and maximum single dose, but the dosage was not adjusted after the warning. A nursing note later documented that the prior Depakote order had been entered incorrectly as 2000 mg TID instead of 500 mg TID, and that the resident had already received several doses before the error was recognized. The resident was noted to have drowsiness after the medication issue was identified.
Unlabeled insulin pens and inhaler in medication cart
Penalty
Summary
Drugs and biologicals used in the facility were not all labeled in accordance with currently accepted professional principles. During observation of the North East medication cart during morning medication pass, two prefilled insulin pens were found open and available for use without an open date: one containing Novolog 100 unit/ml and one containing Glargine 100 unit/ml. RN 2 stated the insulin pens were supposed to have the resident's name and an open date written on them so staff would know when they expired, and that staff should date the insulin when it was taken out of the medication room. During the same medication pass, RN 2 retrieved a Umeclidinium Bromide Inhalation Aerosol Powder 62.5 MCG/ACT inhaler from the bottom drawer of the medication cart after multiple attempts to locate it. The inhaler had no resident identification or open date, yet it was given to resident 9, who took one puff orally. RN 2 stated she was not sure the inhaler belonged to resident 9 but assumed it was because it was with the resident's other medications, then wrote resident 9's name on the inhaler without adding a date. The DON stated staff were expected to write the date on medication when it was pulled from storage, that the medication should already have the prescription label on it, and that medication should not be given if there was no prescription label or if staff did not know who it belonged to.
Failure to Document Annual IPCP Review
Penalty
Summary
The facility failed to conduct an annual review of its infection prevention and control program (IPCP) and did not have documentation showing that the Infection Prevention and Control Policy was reviewed annually. The Policy/Procedure for Infection Prevention and Control, adopted 09/2017, stated that the Infection Prevention and Control Plan would be reviewed annually and updated as indicated by changes in services, changes in the population served, or other changes as appropriate. During an interview on 5/11/26 at 3:29 PM, the DON stated that the IPCP policy was reviewed annually with corporate, but when documentation showing the last review was requested, it was not provided.
Missing Staff COVID-19 Vaccine Documentation and Policy
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure that when the COVID-19 vaccine was available, each staff member was offered the vaccine unless it was medically contraindicated or the staff member had already been immunized. The facility also failed to ensure that, before the vaccine was offered, staff members were provided education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine. In addition, the facility failed to maintain documentation related to staff COVID-19 vaccination, including documentation that staff were provided education, were offered the vaccine or information on obtaining it, and that staff vaccination status was indicated by the CDC's NHSN. Record review showed there was no documentation that four staff members, including a RN, CNA, LPN, and the Dietary Manager, were offered the COVID-19 vaccine. During interview, the DON stated the facility held a flu and COVID-19 clinic every year and that it was open to staff, and she stated every staff member was offered the COVID-19 vaccine but it was not documented. No documentation was provided for any of the four requested staff members showing that they were offered, accepted, or declined the COVID-19 vaccine, and no policy was provided that addressed the required staff COVID-19 vaccine elements.
Failure to Offer and Document Showers for Resident with ADL Deficit
Penalty
Summary
A deficiency was identified when a resident was not offered a shower for a period of 15 days. The resident's care plan, initiated on May 30, 2025, indicated an Activities of Daily Living (ADL) self-care performance deficit related to her diagnoses, with an intervention specifying that she could bathe with one-person staff assistance. The Minimum Data Set assessment dated June 11, 2025, documented that the resident required substantial to maximal assistance for showering or bathing. Review of the shower log showed that the resident received a shower on June 13, 2025, which was the first in 15 days. During an interview, the DON stated that all residents are offered showers twice weekly and that refusals or requests for additional showers are accommodated and should be documented. The DON further explained that the resident had refused showers, but staff failed to document these refusals. Additionally, the DON stated that some showers may have been given but not documented. The lack of documentation and the extended period without a recorded shower led to the finding that the facility failed to provide services consistent with the resident's needs and choices.
Resident Left Unattended in Shower Results in Fall and Injuries
Penalty
Summary
The facility failed to ensure a safe environment for a resident, identified as Resident 118, who was left unattended in the shower, resulting in a fall that caused significant injuries. Resident 118, who had severe cognitive impairment and was dependent on extensive assistance for activities of daily living, was left alone in the shower by a CNA. The CNA had left the resident to retrieve towels and gloves, during which time the resident fell and sustained a head laceration requiring eight staples and six stitches, as well as a pelvic fracture. Resident 118 had a history of Alzheimer's disease, a fracture of the pubis, and a history of falls, among other medical conditions. The resident required extensive assistance from two or more persons for bed mobility, transfers, and toilet use, as documented in the Minimum Data Set (MDS) assessments. Despite this, the CNA left the resident unattended in a shower chair that lacked sides, which was inappropriate given the resident's inability to sit unassisted and her total dependence on care. Interviews with staff revealed inconsistencies in the understanding of the resident's care needs, with some staff believing the resident required only one person for showers, while others acknowledged the need for two-person assistance for transfers. The incident highlights a lack of adequate supervision and failure to adhere to the resident's care plan, which contributed to the accident and subsequent injuries.
Failure to Monitor Blood Pressure Before Administering Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs due to inadequate monitoring of blood pressure as per the physician's order. Resident 33, who had multiple diagnoses including heart failure, hypertension, and chronic kidney disease, was prescribed Amlodipine Besylate with specific instructions to hold the medication if the systolic blood pressure (SBP) was less than 110 or diastolic blood pressure (DBP) was less than 60. However, the resident's blood pressure readings on several occasions were below these parameters, yet the medication was administered without proper documentation or adherence to the physician's order. Interviews with various staff members, including LPNs, MTs, CNAs, and the DON, revealed inconsistencies in the documentation and communication of vital signs. The staff were unclear about where and how the vital signs were recorded, leading to a lack of proper monitoring before administering the medication. The DON acknowledged that the requirement to check the resident's blood pressure was supposed to be removed from the order but was mistakenly left on, contributing to the oversight in monitoring the resident's condition as required.
Non-compliance with PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the administration of psychotropic medications, specifically concerning PRN orders and appropriate indications for use. For Resident 44, a PRN order for Trazodone was not limited to 14 days, and there was no documented rationale from the physician for extending the order. Additionally, the resident was on psychotropic medications, including Aripiprazole and Trazodone, without appropriate diagnoses. The resident's medical history included severe dementia with agitation, type 2 diabetes mellitus, and other complex conditions. Similarly, Resident 28 had a PRN order for Trazodone that was not limited to 14 days, and the physician did not document a rationale for extending the order. Furthermore, the resident was prescribed Quetiapine for delusions without documented behaviors or an appropriate indication for use. The resident's medical history included hemiplegia, type 2 diabetes mellitus, chronic kidney disease, and other significant health issues. Interviews with the DON and ADON revealed that psychotropic medications were reviewed on admission, and the goal was to have a 14-day stop on PRN psychotropics, but this was not consistently implemented.
Unauthorized Lab Tests Conducted Without Physician's Order
Penalty
Summary
The facility failed to obtain laboratory services only when ordered by a physician or authorized practitioner for one resident. Resident 44, who had a complex medical history including orthopedic aftercare, diabetes, and severe dementia, was admitted with specific discharge orders from the hospital. These orders included a two-week antibiotic regimen and a recommendation for certain lab tests to be conducted near the end of the antibiotic therapy. The physician's orders were documented to stop the antibiotics on a specific date, and the required lab tests were ordered to be conducted once before this date. However, additional lab tests were conducted on two separate occasions after the antibiotics had been discontinued, without any documented physician's order. The Director of Nursing and Assistant Director of Nursing indicated that the hospital's order was interpreted to mean that labs should be conducted weekly, even after the antibiotics were stopped. This misinterpretation led to the continuation of lab tests until the resident's follow-up with an infectious disease doctor, despite the absence of a new physician's order for these tests.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Taylorsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rocky Mountain Care - Hunter Hollow | 1.6 mi | ★★★★★ | 19 | 0 |
| Legacy Village Rehabilitation | 4 mi | ★★★★★ | 2 | 0 |
| Alpine Meadow Rehabilitation And Nursing | 4.4 mi | ★★★★★ | 8 | 0 |
| Monument Healthcare Taylorsville | 5.8 mi | ★★★★★ | 15 | 0 |
| Aspen Ridge West Transitional Rehab | 6.8 mi | ★★★★★ | 9 | 0 |
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