Above 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 Neurorestorative during CMS and state inspections, most recent first.
Multiple residents experienced harm due to inadequate supervision and unsafe staff practices. One resident suffered severe burns after being given overheated coffee without a temperature check, another sustained a head laceration after falling from an elevated bed when left unattended, and a third fell during a transfer when staff failed to lock the wheelchair. In each case, staff did not follow required safety protocols, resulting in resident injuries.
A resident with severe cognitive impairment was physically restrained by a respiratory therapist during oral care, as the therapist placed the resident's hands between her knees to prevent movement. The resident became visibly upset and was unable to move her hands, despite an RN offering assistance. The resident's care plan did not include the use of restraints, and staff interviews confirmed that restraint is not standard practice for resistant residents.
A facility did not report an allegation of abuse involving a resident and a respiratory therapist to the State Survey Agency within the required timeframe. The incident, which involved the resident being visibly upset and physically restrained during oral care, was documented internally but not reported as required. The DON could not confirm if the abuse coordinator had submitted the report.
A non-diabetic resident in an LTC facility was mistakenly given Insulin instead of Heparin, resulting in hypoglycemia and hospitalization. The error occurred due to similar labeling and storage of the medications in the same drawer. The resident's condition deteriorated, prompting emergency intervention and hospital admission.
The facility failed to maintain an effective infection control program, as CNAs did not clean the Hoyer lift after each use for residents on enhanced barrier precautions. Observations showed repeated non-compliance, and interviews revealed a lack of consistent adherence to cleaning protocols, with some staff unaware of the requirement. The Infection Preventionist acknowledged the need for further staff education.
A resident with spinal muscular atrophy was injured when a CNA transported her on a utility cart, leading to a fall and resulting in bruising and abrasions. The CNA admitted to using the cart for transport despite it being held together with electrical tape. The incident was witnessed by staff, and immediate care was provided. The CNA had been previously educated on safe transport practices and was suspended and reassigned following the incident.
Failure to Prevent Accidents Due to Inadequate Supervision and Unsafe Practices
Penalty
Summary
The facility failed to ensure that all residents received adequate supervision and that the environment was free from accident hazards, resulting in multiple incidents involving resident harm. One resident, who required staff assistance for feeding and was unable to feed herself, was given reheated coffee by a CNA who did not check the temperature before serving. The resident spilled the coffee, resulting in scalding burns to her torso, abdomen, and right breast, which required hospitalization in a burn unit for wound and pain management. Another resident, who was at risk for falling due to spastic quadriplegic cerebral palsy and required a two-person assist for transfers, fell from his bed and sustained a head laceration requiring sutures. This occurred when a CNA raised the resident's bed in preparation for a transfer and then left the room to retrieve a Hoyer lift, leaving the resident unattended in an elevated position. The resident rolled out of bed during this time, resulting in injury. A third resident, who required maximum assistance with stand pivot transfers and the use of a gait belt, experienced a fall during a staff-assisted transfer. The CNA responsible for the transfer did not lock the resident's wheelchair before initiating the transfer, causing the wheelchair to slip out from under the resident. The resident fell and sustained a bruise to the lower back. In each case, staff failed to follow established protocols for resident safety and supervision, directly leading to resident injuries.
Resident Restrained During Oral Care by Respiratory Therapist
Penalty
Summary
A deficiency occurred when a respiratory therapist (RT) physically restrained a resident during oral care by placing the resident's hands between her knees, restricting the resident's ability to move. The resident, who had severely impaired cognitive skills and was dependent on staff for daily care, became visibly upset and attempted to cover her face during the procedure. Despite the resident's distress and an offer of assistance from a registered nurse (RN), the RT declined help and continued the care while restraining the resident's hands. The incident was witnessed by an RN, who observed that the resident appeared to be in distress and unable to move her hands away. The resident's care plan indicated a history of combative behavior during care and prescribed interventions such as listening to the resident's preferences and using medications for agitation. There were no medical orders for restraints in the resident's records. Interviews with other staff confirmed that the standard practice was to use distraction or a second staff member if a resident was resistant, and not to restrain residents. The facility's policy defined a physical restraint as any method that restricts a resident's freedom of movement, which was consistent with the actions observed during the incident.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse were reported to the State Survey Agency (SSA) within the required 2-hour timeframe. The grievance log showed that the facility received an incident report from a school regarding a possible abuse event involving a respiratory therapist and a resident, where the resident was visibly upset during oral care and the therapist restrained the resident's hands to continue the procedure. Although the facility's abuse coordinator was contacted after receiving the incident report, a review of the SSA's facility reported incident system revealed that the incident was not reported as required. During an interview, the Director of Nursing was unable to confirm whether the abuse coordinator had reported the allegation to the state.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of Insulin instead of Heparin to a non-diabetic resident, leading to hypoglycemia and hospitalization. The resident, who had a complex medical history including anoxic brain damage and cardiac arrest, was admitted to the hospital after receiving 100 units of Insulin, which was mistakenly administered by a nurse who believed she was giving Heparin. The error was discovered when the resident exhibited symptoms of hypoglycemia, such as sweating and discomfort, prompting a blood sugar check that revealed critically low levels. Interviews with nursing staff revealed that the Insulin and Heparin vials were stored together in the medication cart, and both had similar labeling, which contributed to the mix-up. The nurse responsible for the error admitted to not noticing the mistake until after the resident's condition deteriorated. The facility's practice of labeling vials with resident information was in place, but the nurse failed to verify the medication before administration. The Director of Nursing confirmed that the Insulin and Heparin were stored in the same drawer, which was a factor in the medication error. The incident highlighted a lack of adequate safeguards to prevent such errors, as the facility had not implemented sufficient measures to differentiate between similar-looking medications. The resident's mother was present during the incident and was informed of the error, and the resident was subsequently transferred to the hospital for further treatment.
Inadequate Cleaning of Hoyer Lift in Infection Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper cleaning of a Hoyer lift used for resident transfers. Observations revealed that Certified Nursing Assistants (CNAs) did not clean the Hoyer lift after each use, despite its use for residents on enhanced barrier precautions and contact isolation. Specifically, the Hoyer lift was not cleaned after being used for residents identified as 1, 23, and 55, who were on enhanced barrier precautions. This lack of cleaning was observed multiple times, indicating a systemic issue in the facility's infection control practices. Interviews with staff, including CNAs and the Infection Preventionist (IP), highlighted a lack of consistent adherence to infection control protocols. CNA 1 admitted to never cleaning the Hoyer lifts and stated they had not been instructed to do so. CNA 4 was unaware of the requirement to clean the lift after each use, while CNA 2 acknowledged that the lifts were not always cleaned after each resident use. The IP confirmed that staff were expected to clean the Hoyer lifts after each use, especially for residents on precautions, and noted that further education on this matter was necessary.
Resident Injury Due to Inappropriate Transport Method
Penalty
Summary
The facility failed to ensure adequate supervision and services to prevent accidents for a resident diagnosed with infantile spinal muscular atrophy and other conditions. The incident involved a certified nurse assistant (CNA) who transported the resident on a utility cart, which was not intended for resident transport, leading to the cart collapsing and the resident falling to the floor. This resulted in the resident sustaining bruising and abrasions on her forehead and nose. The CNA admitted to using the cart for transporting the resident on multiple occasions and acknowledged that the cart was in poor condition, being held together with electrical tape. The incident was witnessed by a registered nurse and a respiratory therapist, and immediate care was provided to the resident, including neuro-checks and pain management. The assistant director of nursing confirmed that the incident was preventable and that the CNA had previously been educated on safe transportation practices. The CNA was subsequently suspended and reassigned to another area of the facility. The director of nursing and medical doctor were involved in assessing the resident's condition, and a decision was made not to pursue imaging initially, although a scan was later conducted with negative findings.
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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 Riverton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rocky Mountain Care - Riverton | 2.1 mi | ★★★★★ | 0 | 0 |
| Stonehenge Of South Jordan | 4.2 mi | ★★★★★ | 0 | 0 |
| Draper Rehabilitation And Care Center | 4.4 mi | ★★★★★ | 4 | 0 |
| Pointe Meadows Health And Rehabilitation | 5.7 mi | ★★★★★ | 0 | 0 |
| Copper Ridge Health Care | 6.3 mi | ★★★★★ | 3 | 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.