Below 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 Rocky Mountain Care- Clearfield during CMS and state inspections, most recent first.
The facility failed to provide enough nursing staff with the needed competencies to meet resident care needs. Residents reported very long call light waits, delayed toileting, repositioning, transfers, showers, and ADL help, with some waiting over an hour or more and being left in dirty briefs. A resident with major mobility and ADL needs required extensive assistance, while a CNA and the ADON acknowledged staffing problems, heavy reliance on agency staff, and very long response times on certain halls. Resident council notes also documented late meds, inconsistent staffing, poor rounding, and call lights being turned off without needs being addressed.
A resident with a prosthetic arm was not consistently assisted because staff and CNA staff said they did not know how to apply it, and therapy was doing it instead. Other residents reported very long call light waits, delayed incontinence care, and poor ostomy handling that spilled stool and left a resident covered in stool. Another resident was seated at a dining table that was too high for her chin level, and staff acknowledged the table height was not appropriate.
Failure to provide scheduled showers and ADL assistance: A resident with morbid obesity, weakness, and gait impairment was observed with a stained gown and greasy, uncombed hair and reported not receiving daily showers or needed bathing help. The resident stated her hair became matted from lack of washing and had to be shaved by the nurse. Records showed limited shower documentation despite a care plan calling for daily ADL assistance, and staff confirmed the resident was supposed to receive daily showers with refusals documented.
A resident with decreased mobility and weakness was discharged from PT after meeting goals and placed in an RNA restorative program for AROM and transfers. The RNA reported difficulty waking the resident and often did not perform the exercises or transfers when she was asleep, while the resident said she had previously been able to reposition in bed and transfer to her wheelchair during PT. The DON stated the resident now required extensive assistance for repositioning and was dependent for transfers, reflecting a decline in function after PT discharge.
Infection control deficiencies were identified involving a resident on EBP for wound care, a meal-time cross-contamination event between two residents, and an uncapped tube feeding setup for a resident receiving enteral nutrition. Observations and staff interviews showed missing EBP signage and PPE at the resident’s door, a resident using a fork already used to feed herself to mix butter into another resident’s food, and disconnected feeding tubing left uncapped while formula remained in the bag. The DON and IP described the facility’s infection control protocols for EBP, meal assistance, and capping disconnected feeding tubing.
Failure to provide assistance with ADLs: one resident with severe visual impairment was observed receiving a meal tray without the needed setup help, while another resident’s scheduled showers were missed multiple times despite care plan directions for daily ADL assistance. Interviews and record review showed the first resident needed help opening containers and orienting to the tray, and the second resident had altered ADL function after multiple fractures and was supposed to receive scheduled bathing assistance.
A resident who recently returned from a hospital stay for pneumonia suffered a fall resulting in a femur fracture and required transfer to the ED. Staff attempted to contact the primary emergency contact multiple times without success and did not notify additional emergency contacts as required. The family was not informed of the injury or hospitalization until two days later, learning of the situation from the hospital.
A resident with severe cognitive impairment and multiple medical conditions, including diabetes, experienced a delay in receiving appropriate foot care, resulting in toe necrosis. Despite documentation of toe pain, the issue was not addressed by a physician for several weeks, leading to urgent medical intervention. Interviews revealed confusion among staff regarding responsibility for podiatry referrals, contributing to the delay in care.
The facility failed to maintain a safe environment and provide adequate supervision, resulting in injuries to several residents. A resident with a history of falls was unable to call for help due to a broken call light, leading to a hip fracture. Another resident was injured during a transfer attempt by a family member due to delayed staff response. Additionally, a resident was at risk from a damaged bedside table, and another fell due to a bed with a broken locking mechanism.
The facility failed to maintain resident dignity and provide timely care, affecting four residents. A resident was denied a shower for two weeks, and another struggled with eating due to inadequate assistance, leading to a lack of a dignified dining experience. Additionally, two residents experienced significant delays in call light responses, waiting over 30 minutes for assistance.
The facility failed to provide a safe, clean, and homelike environment for residents. A resident reported an unkempt smoking area, while another was observed with a damaged bedside table posing a risk. A third resident fell due to a malfunctioning bed lock, which was not routinely checked. Additionally, several rooms were found unclean, with trash and debris on the floors.
The facility failed to thoroughly investigate abuse allegations for three residents, leading to deficiencies in addressing potential abuse and neglect. A resident reported feeling unsafe and experiencing inappropriate touch, but follow-up actions were not documented. Another resident was allegedly mishandled during care, with inconsistencies in witness statements and missing interviews with supervisory staff. A third resident suffered a fall resulting in a fracture, but the investigation lacked interviews with staff present before the fall, leaving the allegation unverified.
Three residents in the facility did not receive adequate assistance with activities of daily living, specifically in maintaining a regular schedule for showers and bed baths. One resident, dependent on staff for showering, reported receiving showers only once a week, contrary to the scheduled three times per week. Another resident expressed dissatisfaction with the frequency of bed baths, indicating a week-long gap without one. A third resident experienced irregular shower schedules, with significant gaps between showers. The care plans lacked specific references to the residents' needs for assistance with bathing, and there were procedural lapses in documenting refusals and ensuring follow-through on scheduled showers.
The facility failed to provide regular bathing assistance to residents who were unable to perform activities of daily living. Several residents, including those with significant medical conditions, did not receive showers as scheduled, and there were lapses in documentation and understanding of shower refusals among staff. This deficiency affected residents who were dependent on staff for personal hygiene, leading to significant gaps between bathing activities.
The facility failed to ensure timely physician visits for six residents, who were instead seen by NPs, not meeting regulatory requirements. Residents with complex medical conditions, such as Alzheimer's and chronic pain, were not seen by a physician within the required timeframes. The issue was exacerbated by a turnover in the Medical Director position, leading to missed visits.
The facility was found to have insufficient nursing staff, leading to unmet resident needs and safety concerns. Residents reported long wait times for call lights, missed showers, and delayed medications, particularly during night shifts. Staff interviews confirmed understaffing issues, with CNAs unable to complete necessary tasks. Management acknowledged staffing challenges but believed the facility was adequately staffed based on census.
A facility failed to properly label and store medications, leading to deficiencies. A resident with diabetes had insulin pens at the bedside without proper storage, despite facility policy requiring storage in a medication cart. Another resident had a medication pill left at the bedside without an assessment for self-administration. Additionally, expired insulin vials were found, and the medication fridge was at an unsafe temperature, risking medication integrity.
The facility failed to store, prepare, and serve food according to professional standards, with undated food items found in storage areas and unhygienic practices observed among kitchen staff. A dusty vent and peeling paint posed contamination risks, and a lack of proper sanitation for thermometers was noted.
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies. A resident's psychiatric evaluation was missing, another had inconsistencies in wound documentation despite significant toe issues, and a third had discrepancies between progress notes and skin assessments. Interviews revealed inconsistent documentation practices among nursing staff.
The facility failed to implement written policies for feedback and monitoring, leading to unaddressed medical issues and unsafe conditions. A resident's toe issue was neglected for 27 days, resulting in necrosis and surgery. Additionally, several residents experienced accidents due to inadequate supervision, including falls and injuries. Previous deficiencies were also cited again.
The facility failed to document education and consent for influenza and pneumococcal vaccines for three residents. Despite having a process to check vaccination status and update records, the facility did not consistently include consent forms in medical records. Interviews with the ADON and DON revealed gaps in ensuring residents were offered vaccines and in maintaining accurate documentation.
The facility was found to have inadequate ventilation, resulting in persistent odors of bowel movements, urine, and garbage throughout various hallways and areas. Despite using odor fresheners and cleaning agents, the odors remained, indicating insufficient ventilation measures.
The facility failed to provide written notice to two residents before room changes, violating their rights. One resident with multiple medical conditions and another with chronic illnesses were moved without written notification. Staff interviews revealed that only verbal notifications were given, and the facility was in the process of addressing this issue.
A resident's mail was opened by facility staff without consent, compromising their privacy. The mail contained important legal documents related to the resident's divorce and 401K. The Business Office Manager Assistant opened the mail, assuming it was related to Medicaid paperwork, and failed to deliver it promptly. The facility lacked a clear process for handling resident mail, leading to this privacy breach.
Two residents in the facility had discrepancies between their electronic medical records and their POLST forms regarding code status. One resident's EMR showed DNR while the POLST indicated full treatment, and another resident's face sheet showed DNR while the POLST indicated full code. These inconsistencies were confirmed by staff and posed a risk of incorrect medical response.
Insufficient Nursing Staffing and Delayed Resident Assistance
Penalty
Summary
The facility did not provide sufficient nursing staff with the appropriate competencies and skill sets to meet resident needs for nursing and related services. Multiple residents reported long waits for call light response, delays with toileting, repositioning, transfers, showers, and other ADL assistance, and several described being left in dirty briefs or waiting extended periods for help. One resident stated call lights sometimes took forever to be answered and that therapy was often delayed because staff were not available to assist him up. Another resident said she waited over an hour for a brief change after using the call light, and another said she had waited over 2 hours for staff assistance and was still waiting to be boosted in bed when observed by surveyors. The affected residents had significant care needs documented in their records. One resident was assessed as requiring substantial to maximal assistance with toileting, showers, and bed mobility, partial to moderate assistance with upper body dressing, and dependence for lower body dressing and transfers; the care plan called for 2-person assist with transfers and daily ADL assistance. Another resident stated he was non-weight bearing and had incontinent episodes while waiting for staff to respond. A family member for another resident reported that 2 staff were needed for hoyer transfers and that the resident had waited up to an hour for his call light to be answered. A CNA confirmed that staffing varied, that some shifts were not well staffed, that call lights could remain on for 15 minutes when the unit was hectic, and that some showers did not get completed because of low staffing. Surveyors also found supporting evidence in resident council notes and staff interviews. The ADON stated staffing was based on census and acuity, but acknowledged that the 300/400 hall had multiple residents requiring hoyer lifts, that call light wait times were very long, that there was primarily agency staff on that hall, and that weekend staffing was difficult. Resident council notes across multiple months documented concerns about CNAs talking at the desk while call lights were on, late medication administration, inconsistent nurses and CNAs, lack of rounding, rushed care, late showers, nighttime staffing concerns, and CNAs not helping across halls. One resident also reported that staff did not know how to empty her colostomy bag and that she had to wait 45 minutes after the bag exploded.
Failure to Provide Dignified, Timely, and Appropriate Resident Assistance
Penalty
Summary
The facility did not treat residents with respect, dignity, and care in a manner that promoted their quality of life. Survey findings included multiple resident interviews, observations, and record reviews showing that staff were not consistently able to meet residents’ basic needs in a dignified way, including assistance with a prosthetic arm, timely response to call lights, ostomy care, and appropriate dining setup. Resident 63 had diagnoses including weakness, blindness in both eyes, and acquired absence of the left upper limb above the elbow. He told staff during a Resident Council meeting that he wanted staff trained to put on his prosthetic arm and said facility nurses told him they did not know how to do it. He later asked for help putting the arm on, but the nurse did not return, and an IP nurse was observed wheeling him to therapy without attaching the arm. RN and CNA interviews confirmed they did not know how to apply the prosthetic arm and believed therapy handled it. The PT stated therapy had been doing it and that staff should probably be trained, and also stated the resident likely did not wear the prosthetic arm on weekends because therapy staff were not available. Resident 34 and Resident 86 both reported long waits for call lights to be answered. Resident 34 stated he waited 45 minutes and felt unimportant, while Resident 86 stated it sometimes took forever, delayed therapy, and led to his wife helping with incontinence care, cleaning feces and urine, and cutting his fingernails because staff were not available. CNA 1 confirmed that call lights could remain on for 15 minutes during hectic periods and that some residents required prolonged incontinence care. Resident 113, who had Crohn’s disease and an ileostomy, reported multiple episodes of poor ostomy care, including a detached ostomy bag that spilled stool everywhere, being left covered in stool while her call light was on, and another incident where stool burst over her and the immediate area. She also reported staff laughed, left her to clean herself up, and denied her a shower when she requested one. For Resident 21, who had diabetes, heart failure, weakness, and impaired mobility, staff placed her at a dining table that was at chin height; the CNA acknowledged the table was too high, and the UM observed the issue and laughed while noting an adjustable table was needed.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for a resident who was unable to complete those tasks independently, including showers, grooming, and personal hygiene. Resident 1 was admitted and later readmitted with diagnoses including morbid obesity, lack of coordination, weakness, and gait abnormalities. During a concurrent observation and interview, the resident was seen wearing a stained hospital gown with greasy, uncombed hair and stated that she had not received daily showers, needed staff assistance with bathing, and had her head shaved by the facility nurse after her hair became matted from lack of washing. The resident said she had not had a shower in two weeks and had been told several times that she would get one but instead had to sit and wait. The care plan documented that the resident had alterations in ADLs related to incontinence and weakness, with interventions to assist with daily ADL tasks, provide dignity and respect, and encourage independence. Although the task record indicated daily showers, the shower documentation showed only showers on 4/7/26, 4/21/26, and 5/5/26, with bed baths on 4/14/26 and 4/25/26. Staff interviews confirmed that the resident was supposed to be showered daily, that residents who refused were to be asked three times and have a refusal sheet signed, and that shower refusals were scanned into the medical record. The DON stated the resident was a substantial or maximum assist with showering and that the facility had concerns about residents receiving showers as scheduled.
Failure to Maintain ROM and Mobility After Therapy Discharge
Penalty
Summary
The facility failed to ensure appropriate treatment and services were provided to maintain or improve range of motion and mobility for a resident with limited ROM. Resident 1 was admitted and later readmitted with diagnoses including other abnormalities of gait and mobility, other lack of coordination, and weakness. The resident’s care plan stated she had decreased mobility and functional abilities related to respiratory failure and morbid obesity and that she was participating in an AROM/transfers restorative nursing program. Her physical therapy discharge note stated that she could transfer independently with supervision, ambulate 5 feet with minimum assistance, and was independent with bed mobility. After discharge from therapy, the restorative nursing program was to provide AROM exercises to the upper and lower body and transfers between bed and wheelchair several days a week. However, the RNA stated he had difficulty waking the resident because she was a heavy sleeper and would not perform exercises or transfers if she was sleeping; he also stated he had not performed the restorative activities with her for about a month and that refusals were documented when she was asleep. The resident stated the facility counted showering as restorative because it was difficult for her to get up and out of bed, and she said that when she had been in physical therapy she could reposition herself in bed and transfer to her wheelchair. The DON stated the resident typically required extensive assistance for repositioning and was dependent for transfers, and based on current documentation the resident needed substantial to maximum assistance with transfers and partial to maximum assistance with bed mobility, indicating she had declined in function since discharge from physical therapy.
Infection Control Lapses With EBP, Meal-Time Cross-Contamination, and Uncapped Tube Feeding
Penalty
Summary
An infection prevention and control deficiency was identified when Enhanced Barrier Precautions were not consistently implemented for a resident with diagnoses including neutropenia due to infection, cellulitis of both lower limbs, and chronic wounds. The resident had an order dated 3/8/26 for Enhanced Barrier Precautions related to wound care, yet observations on multiple occasions showed no EBP signage on the door and no PPE available for use. The resident stated that her right leg required daily bandage changes and that she wore briefs because she was not able to make it to the bathroom, while a CNA stated she did not know the resident was on Enhanced Barrier Precautions and believed the resident was continent. An LPN stated the precautions had been lifted, but also acknowledged the resident had a leg wound that might be why she was on them. The IP and DON stated that residents with wounds or other increased infection risks were to be placed on Enhanced Barrier Precautions with signage and PPE posted outside the room. A separate infection control issue was observed in the dining room during a meal when a female resident seated next to a blind resident opened a packet of butter and used a fork she had already used to feed herself to mix the butter into the blind resident’s mashed potatoes. The DON stated that infection control protocols require staff to perform hand hygiene between assisting each resident during mealtime and to provide any assistance a resident might need during meals. A third deficiency involved tube feeding equipment for a resident with chronic respiratory failure, dysphagia following cerebral infarction, gastrointestinal hemorrhage, and tracheostomy status. The resident had orders for enteral feeding with Glucerna 1.2 and scheduled disconnect/reconnect times. On multiple observations, the resident’s tube feeding was disconnected and the feeding bag still contained formula, but the bag was left uncapped. An RN stated he would resume the feeding later using the same formula in the bag and that staff did not normally cap the feeding bag tube after it was unhooked from a resident. The DON stated that infection control protocols require staff to cap and hang disconnected feeding bag tubing on the pump.
Failure to Provide Assistance With Dining and Bathing ADLs
Penalty
Summary
Resident 4, who had diagnoses including category 5 blindness in both eyes, chronic kidney disease stage 5 with heart failure, and type 2 diabetes mellitus, was observed in the dining room while a meal was being served. A dietary aide placed the meal tray in front of the resident and walked away without assisting with set-up. Another resident seated nearby opened condiment packets, squeezed mustard onto Resident 4’s plate, opened the milk carton, and mixed butter into the mashed potatoes. A second observation showed the dietary aide again serving the tray and leaving without assisting, while the nearby resident continued helping with the meal. The resident’s record documented that he required setup or clean-up assistance for eating, and the care plan directed staff to provide assistance with meals as needed and to assist with visual appliances. Interviews confirmed that Resident 4 needed help due to poor vision and limited strength and dexterity in his fingers. The resident stated that staff were supposed to orient him to the items on his tray and open containers, but that staff often placed the tray down and left before he had time to request help. He stated that he sometimes had to wait a long time for staff to notice him, and that he was uncomfortable relying on other residents for assistance. The DON stated that the facility expected staff to identify the plate contents, open all containers, and provide any necessary assistance when serving meal trays. Resident 38, who had diagnoses including multiple fractures after a vehicle accident, gait and mobility abnormalities, and other lack of coordination, stated that she had only had three showers and one bed bath since admission. She reported that the facility had shower days and that staff were supposed to ask three times per day if she needed a shower, but that she was not asked on one scheduled shower day. Record review showed that Resident 38 did not receive scheduled showers on multiple dates in April and May 2026. Her care plan documented altered ADL function related to recent fractures and increased assistance with ADLs, with interventions to assist in completing ADL tasks each day. Interviews with nursing staff and the DON indicated that showers were scheduled and documented, that refusals should be recorded, and that if documentation was blank the shower either did not happen or was not documented.
Failure to Notify Resident Representatives After Serious Injury
Penalty
Summary
Staff failed to immediately notify a resident's representatives following a significant accident that resulted in injury and required physician intervention. The resident, who had recently returned from a hospital stay for pneumonia, experienced a fall that led to a displaced femur fracture. Staff assessed the resident, contacted the provider, and obtained an X-ray confirming the fracture. The provider instructed staff to contact the family to determine their wishes for treatment. Multiple attempts were made to reach the primary emergency contact (POA) by phone, but staff were unable to make contact and only possibly left a voicemail. Despite being unable to reach the primary contact, staff did not attempt to notify any additional emergency contacts as required by facility expectations. The resident was transferred to the emergency department for further care. The family was not informed of the hospitalization and injury until two days later, having first learned of the hospital admission from the hospital itself. Interviews confirmed that staff did not consider the incident critical enough to warrant contacting other emergency contacts, contrary to facility policy.
Failure to Provide Timely Foot Care Leads to Resident's Toe Necrosis
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, leading to a serious health issue. The resident, who had severe cognitive impairment and multiple medical conditions including type 2 diabetes mellitus, experienced pain in the right first and second toes, which was documented by staff on January 23, 2024. Despite this documentation, the issue was not addressed by a physician until February 19, 2024, when the toes were found to be red and sore, with the second toe showing signs of necrosis. This delay in addressing the resident's foot condition resulted in the need for urgent medical intervention, including a podiatry referral and vascular studies. The resident's care plan included interventions for diabetes management and skin integrity, but these were not effectively implemented to prevent the complication. The resident's medical records indicated that a podiatry referral was pending for several weeks, and the necessary care was not provided in a timely manner. The facility's staff, including the Physician Assistant, failed to act on the initial reports of toe pain, and the resident's condition worsened significantly over the following weeks. Interviews with facility staff revealed a lack of clarity and responsibility regarding the process for making podiatry referrals. The Director of Nursing and Resident Advocate both indicated that the responsibility for referrals had shifted, and there was confusion about who was accountable for ensuring the resident received timely care. This lack of coordination and communication contributed to the delay in addressing the resident's foot condition, ultimately leading to the need for surgical intervention.
Failure to Ensure Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for several residents. Resident 166, who had a history of falls and multiple medical conditions, experienced multiple falls due to a non-functioning call light, which was not promptly repaired. This resulted in a hip fracture. Despite being alert and oriented, the resident was unable to call for help due to the broken call light, leading to a fall that was not immediately addressed by staff. Resident 60, who required assistance for transfers, was injured when her husband attempted to help her transfer from her wheelchair to her bed. The husband slipped, resulting in the resident dislocating her shoulder and fracturing ribs. The incident occurred because staff did not respond to the call light in a timely manner, leaving the resident and her husband to wait for over an hour without assistance. Resident 20 was observed pulling on a damaged bedside table with sharp edges, posing a risk of injury. Additionally, Resident 80 fell and injured his finger when his bed, which had a broken locking mechanism, rolled during a transfer. The facility did not conduct routine checks on the beds to ensure their safety, and the broken lock was only discovered after the resident's fall. These incidents highlight the facility's failure to ensure a safe environment and adequate supervision for its residents.
Failure to Maintain Resident Dignity and Timely Care
Penalty
Summary
The facility failed to treat four residents with respect and dignity, impacting their quality of life. Resident 259, who was cognitively intact and required assistance for bathing, reported not having a shower for two weeks. When the resident expressed this concern to the Unit Manager (UM 1), the response was dismissive and condescending, failing to address the resident's needs appropriately. The resident's care plan emphasized the importance of dignity and respect, which was not upheld in this interaction. Resident 20, who required substantial assistance with eating due to various medical conditions, was observed struggling during a meal. The staff did not provide adequate support, leaving the resident to attempt eating and drinking independently, resulting in spills and a lack of a dignified dining experience. The resident was left in wet clothing for an extended period, and staff interactions were not supportive or respectful, as evidenced by laughter at the resident's expense. Residents 12 and 50 experienced significant delays in response to their call lights, waiting 33 and 39 minutes, respectively. Resident 12 needed assistance finding personal items, while Resident 50 was hungry and requested food. The prolonged wait times for assistance indicate a failure to provide timely care and respect for the residents' needs, further contributing to the deficiency in maintaining a dignified environment.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several observations and interviews. Resident 259 reported that the smoking area was unkempt, with overflowing cigarette ashtrays and trash cans, and a piece of metal rain gutter was found in the courtyard. Housekeeping staff were unclear about their responsibilities regarding the courtyard's cleanliness, and the Assistant Director of Maintenance admitted that maintenance was responsible but had not cleaned due to winter weather. Resident 20 was observed sitting in a wheelchair with a damaged bedside table that had sharp, jagged edges, posing a potential risk. Despite the observation, the broken table remained in use for several days. Another damaged table was also found in the hallway, indicating a lack of attention to maintaining safe and functional equipment for residents. Resident 80 experienced a fall due to a malfunctioning bed lock, which was not identified until after the incident. The Director of Nursing acknowledged that staff should check bed brakes before transfers, but there were no routine checks by maintenance to ensure bed safety. Additionally, several rooms were observed to be unclean, with puddles, trash, and debris on the floors, further highlighting the facility's failure to provide a clean and safe environment.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse for three residents, leading to a deficiency in addressing potential abuse and neglect. Resident 79, who was admitted with acute respiratory failure and anxiety disorder, reported feeling ignored and unsafe, and mentioned inappropriate touch. Despite these serious allegations, the facility's internal investigation did not document follow-up actions or interviews with all relevant staff members. The Director of Nursing and Administrator acknowledged the resident's communication challenges but did not substantiate the claims, leaving the allegations unresolved. Resident 82, with a history of chronic respiratory failure and traumatic brain injury, was involved in an incident where a CNA allegedly hit the resident's knees against the wall during care. The facility's investigation noted inconsistencies in witness statements and failed to document interviews with supervisory staff, leaving the allegation unverified. The Administrator admitted to not typing up interviews with key staff, which contributed to the incomplete investigation. Resident 86, who had multiple complex medical conditions, experienced a fall resulting in a clavicular fracture. The facility's investigation did not include interviews with staff who might have been present before the fall, and the Administrator could not confirm the resident's activities or care prior to the incident. The lack of thorough investigation into the circumstances surrounding the fall, including potential neglect, resulted in an unverified allegation, highlighting deficiencies in the facility's response to such incidents.
Inadequate Assistance with Activities of Daily Living
Penalty
Summary
The facility failed to ensure that three residents received appropriate assistance with activities of daily living, specifically in maintaining a regular schedule for showers and bed baths. Resident 46, who was dependent on staff for showering due to impairments, reported receiving showers only once a week, contrary to the scheduled three times per week. The medical records corroborated this inconsistency, showing missed showers without documented refusals, and the care plan lacked specific references to the resident's need for assistance with bathing. Resident 3, also dependent on staff for bathing, expressed dissatisfaction with the frequency of bed baths, indicating a week-long gap without one. The medical records showed infrequent bed baths, with no documented refusals, and the care plan did not address the resident's bathing needs. Interviews with staff revealed a lack of communication and documentation regarding the completion of bed baths, with reliance on external hospice services without proper coordination. Resident 60, requiring partial assistance for bathing, experienced irregular shower schedules, with significant gaps between showers. Despite having a care plan that highlighted the need for assistance, the records showed numerous missed showers without adequate documentation of refusals. Interviews with CNAs and the DON highlighted procedural lapses in documenting refusals and ensuring follow-through on scheduled showers, contributing to the deficiency in care provided to the residents.
Failure to Provide Regular Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good personal and oral hygiene. Specifically, residents requiring assistance with bathing were not provided regular showers or bed baths. This deficiency was identified for four residents, each with varying medical conditions that necessitated assistance with bathing. Resident 2, who was dependent on staff for bathing due to multiple medical conditions including hemiplegia and dysphagia, did not receive regular showers as per the physician's orders. The care plan did not reference the need for assistance with bathing, and there were significant lapses between documented bathing activities. Similarly, Resident 259, who required substantial assistance, reported not having a shower for two weeks, and there were documented gaps in the provision of showers following her readmission from the hospital. Resident 82, who was completely dependent on staff for all activities, had multiple instances where bathing activities did not occur, and there were significant gaps between documented showers. The care plan did not address the need for assistance with bathing. Resident 34, who was also completely dependent on staff, experienced numerous missed showers according to the schedule, with no documented refusals or reasons for the missed showers. Interviews with staff revealed inconsistencies in the documentation and understanding of shower refusals, contributing to the deficiency.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that six residents were seen by a physician at the required intervals after admission. Specifically, these residents were seen by a Nurse Practitioner (NP) instead of a physician, which did not meet the regulatory requirements for physician visits. The residents involved had various medical conditions, including Alzheimer's disease, type 2 diabetes mellitus, schizoaffective disorder, and acute respiratory failure, among others. Resident 46, for example, was admitted with multiple diagnoses such as morbid obesity and chronic pain but had not been seen by a physician since admission nearly three months prior. Similarly, Resident 19 went nine months without a physician visit, despite having complex medical issues like Alzheimer's disease and chronic obstructive pulmonary disease. Resident 62 was seen by a physician 69 days after admission, which was beyond the required timeframe. The facility's process for scheduling physician visits involved the Medical Records Staff (MRS) entering residents into the electronic medical record system and scheduling their visits. However, due to a turnover and vacancy in the Medical Director position, there were missed visits in March 2024, contributing to the deficiency. The MRS acknowledged that the previous Medical Director missed several scheduled visits, affecting the compliance with required physician visits for the residents.
Insufficient Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility was found to have insufficient nursing staff with the necessary competencies and skills to ensure resident safety and maintain their highest practicable physical, mental, and psychosocial well-being. Multiple residents and staff expressed concerns about the staffing levels, noting that showers were not provided as scheduled, call lights were not answered in a timely manner, and the environment was observed to be soiled. Specific incidents included a resident slipping on ice and breaking a hip, and another resident developing a sore that went unnoticed due to low staffing levels. Interviews with residents revealed that many experienced long wait times for call lights to be answered, with some waiting up to 45 minutes or more. Residents also reported that there were significant differences in staffing levels between day and night shifts, with night shifts being particularly understaffed. This lack of staffing led to delays in receiving medications and assistance, with some residents having to sit in soiled briefs for extended periods, potentially leading to health issues such as urinary tract infections. Staff interviews corroborated the residents' concerns, with several CNAs stating that the facility was consistently understaffed, leading to an inability to complete necessary tasks such as changing briefs and repositioning residents. Some staff members reported leaving the facility due to the poor working conditions and lack of support from management. The Director of Nursing and the Certified Nursing Assistant Coordinator acknowledged the staffing challenges but believed that the facility was adequately staffed based on census and that management would assist when staffing was at maximum ratios.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, leading to several deficiencies. Resident 21, who has type 2 diabetes mellitus, was observed with insulin pens on his bedside table without proper storage to prevent access by other residents. Although there was a physician's order allowing self-administration, the facility's documentation indicated that medications should be stored in the nursing medication cart. Interviews with nursing staff revealed inconsistencies in the process of self-administration, with some nurses leaving insulin pens at the bedside contrary to the Director of Nursing's (DON) expectations. Resident 92, diagnosed with multiple conditions including schizoaffective disorder and anxiety, was found with a medication pill left at her bedside despite not being assessed for self-administration. Her medical records indicated that she did not want to self-administer medications, and there was no documentation of an assessment for safe self-administration. Similarly, Resident 15, who was severely cognitively impaired, had medications left at the bedside without a physician's order for self-administration, and no assessment was documented to ensure safety. Additionally, the facility failed to manage medication storage properly. Insulin vials were found expired and still available for use, and the medication fridge was at an unsafe temperature, risking the integrity of stored medications. The DON confirmed that medications should not be left at the bedside without a completed assessment and that the fridge's temperature issue was addressed by removing and destroying affected medications.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by multiple observations of improperly stored and undated food items in various storage areas, including the walk-in fridge, freezer, and dry storage. Numerous food items, such as ice cream, buns, pie crusts, cookie dough, whipped topping, frozen pies, and fruits, were found undated in the freezer. Similarly, undated beverages and food items were observed in the walk-in refrigerator, including juices, milk, deli ham, cookies, and vegetables. The dry storage area contained open and undated bags of breakfast cereal and rice. Additionally, the kitchen environment presented physical contamination hazards, with a dusty ceiling vent and peeling paint above a food preparation area. The kitchen staff did not maintain hygienic practices during food preparation and service. One staff member was observed scratching her hair, touching her face, and allowing her soiled sweatshirt to come into contact with food and plates. Another staff member failed to properly sanitize a food thermometer after it was dropped on the ground, merely rinsing it under running water without using a sanitizing solution. An interview with the Dietary Manager revealed that the facility's procedures for checking and labeling food items were not consistently followed, and there was a lack of sanitizing wipes for thermometers, leading to inadequate sanitation practices.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records for three residents, leading to deficiencies in maintaining resident-identifiable information. For Resident 46, a psychiatric evaluation conducted on 2/25/24 was missing from the medical record, as confirmed by the Director of Nursing (DON) during an interview. This omission indicates a lapse in maintaining comprehensive medical records for the resident, who had multiple diagnoses including schizoaffective disorder and depression. Resident 19's medical records showed inconsistencies in documenting skin integrity and wound care. Despite multiple observations indicating no wounds, progress notes revealed significant issues with the resident's toes, including redness, soreness, and necrosis, which required urgent vascular studies. The records also indicated a delay in addressing the resident's condition, as a podiatry referral was pending for several weeks, and there was difficulty in coordinating care with a vascular specialist. For Resident 3, there was a discrepancy between the nursing progress notes and the weekly skin assessments. A wound on the sacrum was reported and treated, yet the skin assessments documented no wound present. Interviews with nursing staff revealed inconsistencies in how wounds were documented, with some relying on progress notes or the Task Administration Record (TAR) rather than the skin assessment forms. This inconsistency in documentation practices contributed to the deficiency in maintaining accurate medical records.
Deficiencies in Policy Implementation and Resident Safety
Penalty
Summary
The facility failed to establish and implement written policies and procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. This deficiency was evident in the lack of appropriate plans of action to correct identified quality deficiencies. Specifically, for one resident, a staff member documented a problem with the resident's toe, which was not addressed by a doctor for 27 days, leading to necrosis and the need for surgery. Additionally, the facility did not ensure that residents received proper treatment and care to maintain mobility and good foot health, as required by professional standards of practice. The facility also failed to maintain a safe environment free of accident hazards and did not provide adequate supervision and assistance to prevent accidents. This was observed in several incidents involving residents, including a resident left unsupervised with a damaged bedside table, a resident falling outside while smoking, a bed not locked in place resulting in a fall, a resident falling during a transfer by a family member, and residents experiencing unwitnessed falls and remaining on the floor for extended periods. These incidents resulted in harm to three residents. Furthermore, during the previous recertification survey, the facility was cited for multiple deficiencies, which were cited again in the current survey.
Deficiency in Immunization Documentation
Penalty
Summary
The facility failed to ensure that each resident's medical record included documentation of education regarding the benefits and potential side effects of influenza and pneumococcal immunizations, as well as documentation of consent or refusal for these vaccines. This deficiency was identified for three residents. Resident 3, who had multiple diagnoses including polyneuropathy and type 2 diabetes, received a pneumococcal vaccine outside the facility, but there was no documentation of consent or education in their medical record. Similarly, Resident 15, with conditions such as schizophrenia and chronic kidney disease, was due for a pneumococcal vaccine, but their medical record lacked documentation of consent or education. Resident 19, diagnosed with Alzheimer's and COPD, received a pneumococcal vaccine at the facility, yet their record also did not contain the necessary documentation. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility had a process for checking vaccination status through the Utah Statewide Immunization Information System and updating records when vaccines were administered. However, the ADON and DON acknowledged that consent forms, which should indicate acceptance or refusal of vaccines, were not consistently documented in the residents' medical records. The DON admitted that there were issues with ensuring residents were offered pneumococcal vaccines and that the facility was working on improving their system for managing immunization records.
Inadequate Ventilation and Persistent Odors
Penalty
Summary
The facility was found to have inadequate outside ventilation, as evidenced by persistent and strong odors throughout various hallways and areas. Observations made over several days revealed strong odors of bowel movements, urine, and garbage in multiple hallways, near rooms, and at nurse stations. These odors were noted at different times of the day, indicating a consistent issue with ventilation and odor management. Interviews with housekeeping staff revealed that they used natural odor fresheners, Pine Sol, and Febreze to manage odors. Despite these efforts, the odors persisted, suggesting that the measures taken were insufficient to address the underlying ventilation issues. The lack of adequate mechanical or window ventilation contributed to the inability to effectively remove these odors from the facility.
Failure to Provide Written Notification for Room Changes
Penalty
Summary
The facility failed to provide written notice to residents before making room changes, which is a violation of residents' rights. Specifically, two residents, identified as Resident 166 and Resident 259, did not receive written notification prior to their room changes. Resident 166, who had multiple medical conditions including a periprosthetic fracture and acute kidney failure, was moved from one room to another without any written notice documented in their medical record. Interviews with facility staff, including a CNA, Social Service Worker, Unit Manager, Resident Advocate, and the Administrator, revealed that the facility's practice was to provide only verbal notifications of room changes, with no written documentation provided to the residents. Similarly, Resident 259, who had a range of diagnoses including cellulitis, chronic respiratory failure, and heart failure, was moved to a different room without any written notification found in their medical record. An LPN interviewed was unaware of the reasons for Resident 259's room change. The facility's staff, including the Administrator, acknowledged that the current process involved only verbal notifications and that they were in the process of addressing this issue to comply with the requirement for written notifications.
Resident Mail Privacy Breach
Penalty
Summary
The facility failed to ensure that a resident had the right to privacy in their communications, specifically regarding mail. Resident 26, who was admitted with multiple medical conditions including cellulitis, orthopedic aftercare following surgical amputation, and type 1 diabetes mellitus, reported that their mail was opened by facility staff on two occasions. The resident stated that the mail contained important legal documents related to their divorce and 401K, and they had to request the same information again when the first letter was not received. The resident expressed that the staff member claimed it was an accident, but the resident disagreed, noting it happened twice. The grievance logs revealed that a concern was logged for Resident 26, indicating that the resident did not want their mail opened by staff and was missing important legal documents. The Administrator acknowledged the issue and stated that the Business Office Manager Assistant (BOMA) opened the mail, believing it was related to Medicaid paperwork due to the letter being addressed in care of the facility. The BOMA had been assisting the resident with Medicaid paperwork and assumed the letter was related to that, leading to the mail being opened and scanned into the resident's file without immediate delivery to the resident. Interviews with the Resident Advocate, Activities Director, and Administrator revealed that the facility's process for handling resident mail was not clearly defined, and there was confusion about when staff could open mail. The BOMA admitted to opening the mail without specific consent from the resident and acknowledged the error in not communicating with the resident first. The BOMA also confirmed that a second letter was opened and delivered to the resident only after they requested it. The lack of a clear process and communication led to the resident's privacy being compromised.
Discrepancies in Advance Directives Documentation
Penalty
Summary
The facility failed to ensure that the residents' right to formulate and have their advance directives accurately reflected in their medical records was upheld. For Resident 92, there was a discrepancy between the electronic medical record (EMR) and the Provider Order for Life-Sustaining Treatment (POLST) form. The EMR indicated a Do Not Resuscitate (DNR) status, while the POLST form documented full treatment, including life-sustaining measures. This inconsistency was confirmed during interviews with the Registered Nurse (RN) and the Director of Nursing (DON), who acknowledged the potential risk of delayed or absent chest compressions due to the incorrect code status displayed in the EMR. Similarly, for Resident 19, there was a conflict between the documented DNR status on the face sheet and the full code status on the POLST form. During an incident where Resident 19 exhibited severe symptoms, the RN was unable to contact the provider, family, or nursing leadership and called 911. The POLST form, which indicated full code, was not initially available in the medical records system, leading to confusion about the resident's code status. The RN later realized that the POLST form had not been submitted for scanning into the system, highlighting a lapse in ensuring accurate and accessible documentation of advance directives.
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 80 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 Clearfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Thatcher Brook Rehabilitation & Care Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Fairfield Village Rehabilitation | 2.8 mi | ★★★★★ | 1 | 0 |
| Pine View Transitional Rehab | 5.1 mi | ★★★★★ | 0 | 0 |
| The Terrace Transitional | 5.3 mi | ★★★★★ | 0 | 0 |
| Mt Ogden Health And Rehabilitation Center | 5.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.