Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Msm Brigham City Llc during CMS and state inspections, most recent first.
Incontinence Care and UTI Evaluation Deficiencies: A resident had a PureWick placed and used before a provider order was obtained, without facility training or documented instructions for use, and developed peri-area redness and a UTI. Another resident who was frequently incontinent had UTI symptoms, but the urine culture was contaminated and there was no documented follow-up after the specimen was not completed.
Kitchen sanitation and dishmachine temperature deficiencies: Surveyors observed multiple soiled kitchen areas, including dust, food debris, dried substances, and dirty equipment, along with improperly stored food in a refrigerator, including an expired supplement, unlabeled items, and food without dates. The dishmachine was operating below the temperatures staff identified as required, and dishes were returned to use without being dipped in sanitizer solution after processing.
Insulin pens were not properly labeled or tracked for expiration for three residents. During medication cart observations, one resident had an opened Lispro pen with no open date, and two other residents had Lispro pens with open dates recorded. RN, CMT, and DON interviews confirmed that opened insulin pens are good for 28 days and then should be discarded.
Missing Laboratory Results in Resident Records: Survey review found that lab reports were not filed in the charts for multiple residents. Missing documentation included urine culture results, CBC, BMP, VIT D, CMP, ESR, and CRP results, and one CBC was later found to have been cancelled because the sample was clotted. Staff, including the DON and Corporate QA Nurse, were unable to locate the results in the medical records and obtained some reports directly from the lab website or lab after the surveyor requested them.
No qualified food service director was in place, and the facility lacked a full-time designated DM. The DM worked at a sister facility and only helped in the kitchen, while the ADM stated the prior DM had been terminated and the new DM had not yet started. The DM reported the facility had been without a DM since before Thanksgiving and that she had worked only about 36 hours total over the prior 3 weeks.
Meals were not consistently served at an appetizing temperature or in a palatable condition for several residents. Residents reported cold food, bland taste, and unappealing presentation, and surveyors observed a test tray served without a warmer, with lukewarm entrees, a melted dessert, and pie served separately at a frozen temperature. Resident council minutes also showed repeated complaints that meals were cold, not fully cooked, and not matching the menu.
Incomplete and conflicting medical record documentation was found for three residents. One resident with atrial fibrillation had multiple INR orders with different directions, missed INR checks, and inconsistent charting about warfarin management. Another resident received Metoprolol Succinate ER even though the order listed Metoprolol Tartrate, and staff said the pharmacy sent the medication and the order had been entered incorrectly. A third resident’s IV antibiotic orders listed diabetes mellitus as the diagnosis instead of osteomyelitis, and the DON confirmed the diagnosis was documented incorrectly.
Failure to notify physician when ordered meds were unavailable: A resident with dementia and hypothyroidism had Levothyroxine and Donepezil held or not administered because the meds were not available in the facility. The MAR and progress notes showed the meds were missing or not given on multiple occasions, but there was no documentation that the MD was notified. RN and DON interviews confirmed staff expected to notify the resident, resident representative, and physician and document the notification.
A resident with multiple diagnoses was transferred to the ER after a fall, elevated BP, and chest pain, but the chart lacked a completed transfer/discharge assessment and did not show what information was sent to the receiving provider. The record also had no documentation that the Ombudsman was notified of the transfer, and interviews with the RA, RN, and DON confirmed the missing documentation.
A resident with cognitive impairment and repeated unsafe power wheelchair driving had multiple accidents and injuries after therapy documented he could not drive independently without restrictions, yet the record did not show consistent supervision while he used the chair. Another resident who required extensive 2-person assistance for toileting and transfers fell from the bed during incontinence care when one CNA left to get supplies and the other rolled the resident by herself, resulting in facial abrasion and pain.
A resident with dementia, CKD, asthma, hypothyroidism, and other diagnoses did not receive ordered Levothyroxine and Donepezil because the medications were not available from the pharmacy or facility stock. The MAR showed missed or unavailable doses, and RN and DON interviews confirmed that staff were responsible for reordering and checking available inventory when medications were not on hand.
Failure to Notify Practitioner of Cancelled CBC Result: A resident with multiple diagnoses including sepsis, CKD, DM2, and Alzheimer's had a CBC and CMP ordered for suspected pneumonia. The CBC was drawn but later found to be cancelled because the sample was clotted, and the record contained no nursing note showing the ordering practitioner was notified or that the cancelled result was documented.
A resident with paroxysmal atrial fibrillation, repeated falls, and unspecified tremor had a head CT ordered for increased confusion and a high INR, and was transported to the hospital for the test. Surveyors found the CT results were not filed in the medical record, and the DON stated she had to request the report from the hospital because it was missing from the chart.
Incontinence Care and UTI Evaluation Deficiencies
Penalty
Summary
The facility did not ensure appropriate care for residents who were incontinent of bladder and did not ensure appropriate catheter-related care and UTI prevention practices. For one resident, a PureWick was placed and continued to be used before a provider order was obtained, and the record did not contain treatment orders with instructions for its use or monitoring. Facility staff stated they had not received training on PureWick use, and multiple staff members said they did not know how often it should be changed or how it should be cared for. The DON also stated that the facility had not provided training on PureWick use and that the risks included skin breakdown and UTIs. The resident involved had diagnoses including fractures of both femurs, repeated falls, and overactive bladder. Progress notes documented that the PureWick was brought from home and placed on the resident, that staff and family continued to want it used, and that redness developed in the peri area and groin/labia while it was being used. The resident later complained of pain and odor, a urine sample was collected, and the resident was treated for a UTI. The record showed the PureWick had been used for several days before the physician order was entered. A second resident, who was frequently incontinent of bladder and had diagnoses including diabetes and chronic kidney disease with heart failure, had a urine specimen collected after reporting dysuria, increased frequency, lethargy, elevated temperature, cloudy urine, and a strong odor. The UA/C&S result later showed mixed flora and contamination, and the culture was not completed. The record did not contain the lab results at the time they were requested, and there was no documented follow-up in the progress notes regarding the contaminated specimen or the decision not to repeat the UA because the resident was already receiving Keflex.
Kitchen sanitation and dishmachine temperature deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial kitchen tour, surveyors observed a substance on the freezer floor, dust on the front vent of the ice machine, food particles and dried substances under the shelf above the steam table, a soiled warming drawer, and a dried white substance on the wall by the grill. The cleaning schedule showed the ice machine was due to be cleaned inside and out on Tuesday night, but there was no signature documenting completion. In the activities room refrigerator, surveyors observed a Boost Glucose Control container with a use-by date of 10/30/25, an unlabeled container with a white substance and no date, an open McDonalds bag labeled with a room number and dated 12/7, and four plastic grocery bags containing food with no dates. These observations showed multiple items stored without proper labeling or dating and one item kept past its use-by date. On follow-up kitchen observation, the dishmachine was operating below the temperatures staff identified as required for sanitation. The wash and rinse temperatures observed were 140/140, 135/140, 138/140, and 138/140, and dishes, plate lids, meal trays, bases, and plates were returned to use without being dipped in sanitizer solution. The Dietary Aide stated the dishmachine needed to reach 155 for washing and 180 for rinsing, that the temperatures had been low for a month or two, and that the repair company had been called. Additional kitchen observations included dust on a ceiling vent above food prep, dust on hanging pots and pans and their rack, debris and white splatter on a prep table shelf, dried food inside the microwave, dirty and broken utensil drawers, and a dried brown liquid substance on the ceiling and walls by the soda boxes.
Insulin Pens Not Properly Dated or Discarded After Expiration
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles for 3 of 25 sampled residents. During observation of medication cart 2, Resident 1 had an opened Lispro insulin pen that did not have an opened date, and Resident 3 had a Lispro insulin pen with an opened date. During observation of medication cart 1, Resident 15 had a Lispro insulin pen with an opened date. RN 1, CMT 1, and the DON each stated that opened insulin pens are good for 28 days after opening and then should be discarded, and the DON stated that nursing staff and unit clerks should check medications weekly to ensure they are not expired.
Missing Laboratory Results in Resident Records
Penalty
Summary
Complete, dated laboratory records were not maintained in the residents' clinical records for 5 of 25 sampled residents. Survey review found missing urine culture and blood laboratory results for multiple residents, and one resident's clotted sample result was not located in the medical record. The missing records involved residents 3, 7, 8, 33, and 56, and the facility staff were unable to locate the expected laboratory documentation during the survey review. Resident 56 had diagnoses including fracture of the left femur, fracture of the right femur, repeated falls, and overactive bladder. After an infection prevention/control note documented a urine dip and physician notification for possible UTI, with an order for Septra and urine C&S, the urine culture results could not be found in the resident's medical record. The DON stated she was unable to locate the urine culture results and said Medical Records uploaded records to resident charts, with results expected within one business day. Resident 3 had diagnoses including hypo-osmolality and hyponatremia and chronic kidney disease with heart failure. A physician ordered UA with C&S for possible UTI, and the record later showed the lab reported mixed flora, probably contamination, with the C&S not completed; however, the laboratory results were not in the resident's record until the surveyor requested them. Resident 33 had diagnoses including myopathy, sepsis, pneumonitis due to inhalation of food and vomit, and Alzheimer's disease; a CBC and CMP were ordered, the CMP was present, but the CBC was missing from the record and later obtained from the lab as a cancelled clotted sample. Resident 7 had diagnoses including attention to colostomy, atrial fibrillation, schizophrenia, epilepsy, and neuromuscular dysfunction of bladder; CBC, BMP, and VIT D results collected for the ordered labs could not be located in the record. Resident 8 had diagnoses including cutaneous abscess of chest wall, cellulitis, osteomyelitis, dementia, chronic kidney disease, major depressive disorder, anxiety disorder, asthma, hypothyroidism, and insomnia; CBC, CMP, ESR, and CRP results ordered for the resident could not be located in the medical record, and the DON stated the facility would call the lab if results were not received.
No Qualified Food Service Director
Penalty
Summary
The facility did not employ a full-time, designated person to serve as the director of food and nutrition services and did not have a qualified food service director. During interview, the Dietary Manager stated she worked at a sister facility and only helped in the kitchen because there was no full-time DM, and she identified herself as a Certified Food Manager with a certification expiration date of 8/1/26. The Administrator stated the previous DM had been terminated, a new DM had been hired but could not start until 12/18/25, and in the meantime the facility was being helped by a DM from another facility and the Maintenance Director, who was off that week. In a follow-up interview, the DM stated the facility had been without a DM since before Thanksgiving and that she only stopped by in the mornings before going to her own facility, working approximately 36 hours total in the last 3 weeks.
Meals Served at Improper Temperature and Poor Palatability
Penalty
Summary
Food and drink were not consistently served at a palatable, attractive, and safe appetizing temperature for 4 of 25 sampled residents, including residents 11, 21, 35, and 39. During interviews, resident 39 stated the food was sometimes cold, resident 21 stated the food had good days and bad days, was often cold, and did not look appetizing, resident 35 stated food items were not served at the correct temperature and sometimes were cold, the taste and preparation were not appealing, and oatmeal was served without milk, and resident 11 stated the flavor of the food was sometimes bland. An observation of the posted meal and test tray showed the meal was served from a cart without a warmer under the plate, and the stainless steel cover was tarnished with a white substance. Recorded temperatures from the test tray included turkey roast at 122.7 degrees, vegetables at 110.1 degrees, green bean casserole at 116.7 degrees, and vanilla ice cream at 29.7 degrees; the food was described as lukewarm, not palatable, and the ice cream was melted to a liquid consistency. Pie was brought out separately after the meal rather than served with the trays, and an observation found the pie temperature was 22 degrees with the middle frozen. Resident council minutes also documented repeated concerns that meals were not hot, not fully cooked, not what residents ordered, and not matching the menu. The Administrator stated food had been discussed in QAPI and that the DM had been terminated because of lack of response to residents regarding food.
Incomplete and Conflicting Medical Record Documentation
Penalty
Summary
The facility did not maintain complete and accurately documented medical records for 3 of 25 sampled residents. The record review and interviews showed conflicting documentation for INR monitoring and warfarin management for a resident with paroxysmal atrial fibrillation and repeated falls. The chart contained multiple INR orders with different directions and timeframes, and the facility incident report stated that INR checks were not completed on two ordered days. Progress notes later documented an elevated INR, provider notification, and additional lab orders, while staff interviews showed confusion about which INR order was correct and whether the missed INR checks were actually errors. A second resident’s medication record contained conflicting documentation for metoprolol. The physician order in the chart listed Metoprolol Tartrate 50 mg by mouth in the morning for hypertension, but during medication pass the resident received Metoprolol Succinate ER 50 mg. The medication technician stated the succinate formulation was given because that was what the pharmacy sent and that she did not know the difference between the two formulations. The DON stated the resident’s hospital discharge orders were for Metoprolol Succinate and that the medication order had been entered incorrectly. A third resident’s record showed intravenous antibiotics documented with an incorrect diagnosis. The orders listed Vancomycin and cefTRIAXone for type 2 diabetes mellitus without complications for 6 weeks, while a nursing progress note stated the resident had osteomyelitis and Vancomycin was ordered. The DON stated that Vancomycin and Ceftriaxone were antibiotics and would not be used for type 2 diabetes mellitus, and that the diagnosis for the antibiotics should have been osteomyelitis. The DON also stated that nurses or unit clerks entered the orders into the medical record and that the unit clerk and nurse typically double checked orders for accuracy.
Failure to Notify Physician When Ordered Medications Were Unavailable
Penalty
Summary
The facility failed to immediately consult the resident’s physician when there was a need to alter treatment for one sampled resident. Resident 8, who had diagnoses including dementia and hypothyroidism, had physician orders for Levothyroxine Sodium 25 micrograms daily and Donepezil Hydrochloride 5 milligrams in the evening. The resident’s November 2025 MAR showed Levothyroxine documented with a code 9 on 11/3/25 and 11/4/25, with a progress note stating the medication was not in the facility and would be reordered from the pharmacy. The MAR also showed Levothyroxine not documented as administered on 11/9/25 and 11/11/25. The MAR further showed Donepezil documented as not available on 11/17/25 through 11/19/25. No documentation was found that the resident’s physician was notified that either medication was not administered as ordered. During interview, RN 3 stated that if medications were unavailable, she would notify the resident, the resident representative, and the physician, and document those notifications in the progress note linked to the MAR. The DON stated that when a medication was not available, staff should determine why it was missing, notify the pharmacy, notify the physician, and document the physician notification in a progress note.
Missing transfer documentation and Ombudsman notice
Penalty
Summary
The facility did not ensure that a resident’s transfer to the emergency room was documented in the medical record or that the required information was communicated to the receiving health care provider. Resident 8, who had diagnoses including cutaneous abscess of the chest wall, cellulitis, osteomyelitis, dementia, chronic kidney disease, major depressive disorder, anxiety disorder, asthma, hypothyroidism, and insomnia, had a fall followed by elevated blood pressure and reported chest pain, prompting a 911 call and a non-emergent transfer to the hospital. The resident’s record documented that family, the medical provider, and nursing administration were notified, and the hospital later documented treatment for a urinary tract infection, fall, and confusion. Record review found no documentation of a transfer/discharge assessment or of what information was sent to the receiving provider for the transfer. The ER Transfer Assessment form included a section for transfer documentation, but it was not completed for this transfer. The record also contained no documentation that the Office of the State Long-Term Care Ombudsman was notified of the transfer. Interviews with the Resident Advocate, RN 2, and the DON confirmed that the Ombudsman notification was not documented and that the transfer/discharge assessment had not been completed.
Failure to Supervise Wheelchair Use and Provide Required Two-Person Assistance
Penalty
Summary
The facility did not provide adequate supervision to prevent accidents for a resident who used a power wheelchair and had diagnoses including myopathy, Alzheimer's disease, diabetes, chronic kidney disease, neuropathy, and later documented dementia. After the resident ran into his bed while in the wheelchair and sustained a left leg laceration requiring emergency transport and staples, therapy completed a wheelchair safety evaluation that stated he was not able to drive independently without restrictions. The record also showed repeated observations that he had poor safety awareness, bumped into objects, and had difficulty navigating safely in the wheelchair. Despite those findings, the resident continued to use the power wheelchair and sustained multiple additional injuries. Nursing notes and physician documentation described further lacerations, hematomas, skin tears, and abrasions after he struck beds, a therapy desk, a soda machine cabinet, and bathroom walls while operating the wheelchair. The record also showed that staff and therapy continued to reassess his wheelchair use over time, and that he was at times allowed to use the power wheelchair with supervision by family, but the documentation did not show consistent supervision when he was using it. The administrator stated there was no documentation of how staff supervised him while he used the power wheelchair. The facility also did not provide the level of assistance needed during incontinence care for another resident who was dependent for transfers and toileting. The resident’s MDS documented extensive 2-person assistance for bed mobility, toileting, and transfers, and staff interviews confirmed the resident was totally dependent and required 2 staff for incontinence care. During a brief change, one aide left the room to get supplies and the other aide began rolling the resident by herself; the resident then rolled off the bed and was lowered to the floor, sustaining an abrasion to the face and a scratch above the eye, with pain reported in the wrist. The incident report did not identify the CNA witnesses, and the care plan intervention requiring 2 staff for incontinence care was added after the fall.
Medication Not Available for Ordered Treatments
Penalty
Summary
Pharmaceutical services did not provide routine and emergency drugs and biologicals to meet the needs of Resident 8. Resident 8 was admitted and later re-admitted with diagnoses including cutaneous abscess of the chest wall, cellulitis, osteomyelitis, dementia, chronic kidney disease, major depressive disorder, anxiety disorder, asthma, hypothyroidism, and insomnia. The resident had physician orders for Levothyroxine Sodium 25 mcg daily for hypothyroidism and Donepezil Hydrochloride 5 mg in the evening for psychotropic use. The November 2025 MAR showed that Levothyroxine was documented with code 9 on 11/3/25 and 11/4/25, with progress notes stating the medication was not in the facility and would be reordered from the pharmacy. Levothyroxine was also not documented as administered on 11/9/25 and 11/11/25. Donepezil was documented as not available on 11/17/25 through 11/19/25. RN 3 stated that nurses were responsible for reordering medications when blister packs reached the refill date, checking the cart and Pixus for available stock, and entering a stat order if needed. The DON stated that if medication was not available, nursing staff should determine why it was not at the facility, notify the pharmacy, and check the stat safe and OTC supply for inventory availability.
Failure to Notify Practitioner of Cancelled CBC Result
Penalty
Summary
The facility failed to promptly notify the ordering practitioner of laboratory results when a CBC ordered for Resident 33 was not completed as ordered because the specimen was clotted. Resident 33 was admitted with diagnoses including myopathy, sepsis, pneumonitis due to inhalation of food and vomit, Alzheimer's disease, type 2 diabetes mellitus, chronic kidney disease, and hereditary and idiopathic neuropathy. A physician order dated 5/31/25 directed staff to complete a CBC and CMP, and a nursing progress note documented that the CBC and CMP were drawn and sent to the local hospital lab on a STAT order for suspected pneumonia. The CBC was not found in the resident's medical record, and there were no nursing progress notes documenting CBC results or physician notification. During survey review, the Corporate Quality Assurance Nurse provided CBC results showing the test was cancelled because the sample was clotted. She stated the CBC on 5/31/25 had no results because it was clotted and that there were no nurses' notes about the sample being clotted and cancelled. The DON stated the nurse was expected to notify the physician of results and document that notification in a progress note, but the record reviewed did not contain documentation that the physician was notified about the cancelled CBC or whether a new lab draw was ordered.
Missing CT Report in Resident Record
Penalty
Summary
Keep signed and dated reports of x-rays and other diagnostic services in the resident's record was cited after surveyors found that one of 25 sampled residents did not have radiologic reports filed in the clinical record. Resident 14 was admitted with diagnoses including paroxysmal atrial fibrillation, repeated falls, and unspecified tremor. The resident's record showed that on 8/18/25 a nurse documented that the provider ordered a head CT due to increased confusion and a high INR, and that the resident was transported to and from the hospital for the appointment. However, the head CT results could not be located in the medical record. During interview, the DON stated she had to request the head CT results from the hospital because they were not in the record, and stated that radiology results should be uploaded into the medical record under the miscellaneous tab.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 96 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Brigham City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monument Healthcare Pioneer Trail | 0.2 mi | ★★★★★ | 0 | 0 |
| Monument Healthcare Brigham City | 2.4 mi | ★★★★★ | 7 | 0 |
| George E. Wahlen Ogden Veterans Home | 14.9 mi | ★★★★★ | 0 | 0 |
| Lomond Peak Nursing And Rehabilitation | 15.4 mi | ★★★★★ | 0 | 0 |
| Sunshine Terrace Skilled Nursing | 19.4 mi | ★★★★★ | 16 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Msm Brigham City Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.