Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 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.
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.
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 | ★★★★★ | 0 | 0 |
| Monument Healthcare Taylorsville | 5.8 mi | ★★★★★ | 15 | 0 |
| Aspen Ridge West Transitional Rehab | 6.8 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.