Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 - Logan during CMS and state inspections, most recent first.
Three residents did not receive timely assessment and treatment in response to serious changes in condition. One resident on anticoagulation with mobility issues fell in the bathroom, later developed headache, vomiting, lethargy, and unilateral weakness, and was not transferred to the ED for approximately 2.5 hours after these changes, where a large subdural hematoma was found and the resident later died. A second resident with Parkinsonism and mobility impairment fell, immediately complained of left hip pain, and remained in pain despite analgesics while staff awaited imaging; transfer to the hospital for a confirmed femoral neck fracture did not occur until about 10 hours after the fall. A third resident with muscular dystrophy, OSA, and dysphagia had multiple episodes of severely low O2 sats, including readings in the 40s and 50s with cyanosis, without consistent or prompt interventions, follow-up sats, or documentation, and staff described delays in notifying a nurse and initiating oxygen despite obvious hypoxia.
A resident admitted with surgical wounds and MASD, and identified as high risk for pressure sores by Braden Scale, did not receive pressure ulcer prevention and wound care consistent with professional standards. Initial wounds on the posterior left lower extremity related to a brace and coccyx MASD were documented without measurements or detailed descriptions, and an order for barrier cream with each incontinent episode lacked evidence of administration. Over time, the resident developed additional skin breakdown on the sacrum, left inner thigh, left great toe, left posterior calf, and hips, including multiple Stage 4 pressure ulcers, but documentation of wound onset, measurements, descriptions, and preventive interventions was incomplete or absent. A knee immobilizer was ordered twice daily without specific care instructions, and the resident later developed a Stage 4 ulcer on the calf where the immobilizer was applied. Physician notes identified Stage 4 ulcers on the left shin, left hip, right hip, and posterior left lower leg, yet corresponding wound treatments were not consistently reflected on the MAR, and the Administrator could not provide additional documentation of preventive measures beyond the existing record.
A resident with weakness and orthostatic hypotension fell and hit his head after being left alone in the shower, despite needing supervision or more assistance with bathing. Another resident with paraplegia was injured in a van crash when the wheelchair seatbelt was not secured properly, and the driver had no documented training on safely transporting residents. Surveyors also found multiple room sinks with water temperatures above 120 degrees, including readings up to 130.2 degrees.
Food was not stored and handled according to professional standards. Surveyors found undated drinks, frozen vegetables, buns, and refrigerated items, an opened bag of corndogs left exposed to air, expired evaporated milk in dry storage, and expired sandwiches and a snack pack in a resident refrigerator. On a follow-up tour, the sanitizer bucket tested at 75 ppm when the DM stated 100 ppm was required, and additional refrigerated items were still undated.
Failure to Thoroughly Investigate Abuse and Neglect Allegations: The facility did not have evidence of thorough investigations for multiple allegations involving resident injury, a van accident, staff misconduct, inadequate care, self-harm, and alleged spousal abuse. A resident with dementia and other diagnoses sustained a fracture after a fall, another resident reported being thrown from a wheelchair in a van crash with a drowsy driver, and several other residents reported CNA misconduct or neglect, but investigation records were not available.
The facility failed to maintain an infection prevention and control program. Staff handled a resident’s feeding tube without the full EBP described in the report, including not using gowns and leaving the tube uncapped when not in use. Another resident who was ordered EBP for a catheter and wounds had no EBP sign or supplies observed in or outside the room. During lunch service, a CNA touched a resident’s food bare handed and also handled another resident’s sandwich bare handed.
The facility failed to ensure that two residents’ discharges and non‑readmissions were justified, coordinated, and accurately documented. One resident with terminal liver cancer and on hospice, whose care plan called for continued LTC, showed clear clinical decline in provider and hospice notes with no mention of discharge, yet was discharged the same day using an outdated discharge summary from a prior stay that listed an incorrect date, an RV destination, and home health instead of hospice, while hospice staff were not informed in advance and social services was not involved. Another resident with TBI, paraplegia, major depression, antisocial personality disorder, and suicidal ideation was discharged after repeated episodes of severe aggression and self‑harm, but the record lacked physician documentation explaining why the facility could not meet the resident’s needs, what interventions were attempted, and why the resident was not readmitted, despite staff interviews describing blue‑sheeting, suicide attempts, and safety concerns. The facility also failed to care plan aggressive behaviors for one resident and did not document coordination with hospice or behavioral interventions before discharge.
Failure to report a transport accident involving resident injury: A resident with paraplegia and PTSD was injured when the facility van went off the road and through a fence, causing the resident to be thrown from the wheelchair after the seatbelt was not secured properly. The resident reported bruising to the ribs and said the driver appeared drowsy. Facility records showed no documentation of the incident and no evidence it was reported to the SSA; the VPPA said she investigated but did not report it, and the ADM said the only record was the physical asset investigation.
Improper Tube Feeding Handling and Incomplete Formula Labeling: A resident with a PEG tube had feeding stopped, disconnected, reconnected, and restarted by CNA and restorative staff even though nursing staff stated only nurses were allowed to handle tube feeds. The resident’s formula bag was also labeled incompletely, with staff noting that tube feed labels should include the date, time, and nurse initials, consistent with nursing procedure guidance.
Medication Given Despite Hold Parameters: A resident with hemiplegia/hemiparesis following CVA, acute kidney failure, and idiopathic hypotension had an order for furosemide 20 mg daily with hold parameters for low BP. The MAR showed the medication was administered multiple times when BP readings were below the ordered limits, and an RN and the ADON stated the medication should be held when parameters were not met.
A resident with hemiplegia and hemiparesis after a CVA did not have her call light within reach while in bed. During observation, the call light was clipped to the top of the bedsheet on the left side, out of the resident’s reach, even though the resident stated staff were supposed to clip it to her shirt so she could reach it with her right hand. Interviews and record review showed this had happened before, and staff acknowledged the call light needed to be within reach because of the resident’s left-sided paralysis.
The facility failed to provide necessary housekeeping and maintenance services, resulting in cracked and broken drywall, peeling paint, a sticking door handle, and a loose toilet in three residents' rooms. Despite being aware of the issues, the Maintenance Director did not address them in a timely manner, and the Administrator was unaware of the extent of the needed repairs.
The facility failed to ensure medication error rates were below five percent, with a 16% error rate observed. Medications meant to be taken before meals were given post-meal to four residents. RN 3 acknowledged the errors, and the DON confirmed the need to follow doctor's orders for medication administration.
The facility failed to ensure a resident was evaluated for self-administration of medications. Medications were found at the bedside of a resident with severe cognitive impairment and multiple diagnoses, without proper assessment or physician's order. Staff confirmed the resident was not authorized to have medications at their bedside.
The facility inaccurately coded a resident as having received insulin during the seven-day MDS observation period when no insulin was administered. The resident's medical record and Medication Administration Record confirmed the absence of insulin orders or administration, which was acknowledged by the MDS Coordinator.
A resident with severe cognitive impairment and asthma experienced a delay in receiving timely treatment for respiratory symptoms. Despite family concerns and low oxygen levels, the resident was only given nasal spray and Mucinex over the weekend. The physician assistant ordered appropriate interventions on Monday, highlighting a failure in timely care and communication among staff.
A resident with multiple diagnoses, including chronic inflammatory demyelinating polyneuritis and muscle weakness, did not receive recommended restorative nursing services to improve range of motion (ROM). Despite a care plan and physical therapy evaluation recommending PT and participation in a restorative nursing program, the facility failed to provide these services, and the resident was not offered alternative therapies or exercises.
A resident with multiple diagnoses and increased protein needs did not receive the recommended Liquacel supplement twice a day for wound healing. The Liquacel was unavailable for four administrations, and there were issues with ordering and stocking the supplement. Staff interviews revealed inconsistencies in following dietary recommendations and delays in receiving supplies.
A resident was not administered a prescribed protein supplement for wound healing due to it being unavailable. Staff interviews revealed issues in the ordering and stocking process, leading to missed doses and the resident receiving an alternative supplement instead.
The facility failed to act on a pharmacist's recommendation to discontinue atorvastatin during daptomycin therapy for a resident, resulting in the resident receiving both medications concurrently for an extended period. The delay was attributed to the DON being on vacation and the usual process for handling recommendations being disrupted.
Delayed Response to Falls and Hypoxia Resulting in Resident Harm
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessment and treatment in response to changes in condition after falls and episodes of hypoxia, resulting in harm to residents. One resident with paroxysmal atrial fibrillation, difficulty walking, muscle weakness, and on anticoagulant therapy with an elevated INR experienced an unwitnessed fall in the bathroom. She was found on the floor in soiled clothing, assisted back to the toilet, and then to a chair. Initial neuro checks and vital signs were documented as baseline, and she denied hitting her head with no signs of injury noted. Later neuro documentation showed elevated blood pressure and lethargy, with slow response to verbal stimuli, weakness in hand grasps, and slurred speech, but there was no documented immediate escalation of care at that time. Subsequently, the resident began complaining of a headache and then reported that she had hit her head at the time of the fall. Nursing notes documented nausea, vomiting, not following simple cues, and left-sided weakness in grip strength. Staff interviews indicated that a CNA reported the headache to the nurse, who administered medications including Tylenol and performed neuro checks, noting rising blood pressure but otherwise within normal limits at that time. When the resident vomited and her level of consciousness changed, with inability to open her eyes and no grip in the left hand, the nurse notified the wing nurse, who then initiated notifications and arranged for transfer. The resident was ultimately sent to the emergency department approximately 2.5 hours after the onset of significant change in condition, where a CT scan revealed a very large right subdural hematoma with midline shift and herniation. The facility later provided additional information but did not explain the 2.5-hour delay in sending her to the hospital after the change in condition, and the resident subsequently died. Another resident with Parkinsonism, muscle weakness, difficulty walking, and sepsis sustained an unwitnessed fall and was found lying on the floor next to the bed, complaining of left hip pain. The nurse documented no new bruising or redness at the time, initiated neuro and vital sign checks, administered pain medication, and notified management, the physician, and family. An order was placed for a left hip x-ray, and the resident continued to receive oxycodone for left hip pain, with one dose documented as ineffective. The resident was not discharged to the hospital until later that afternoon, when an x-ray confirmed a left femoral neck fracture, resulting in a delay of approximately 10 hours from the time of the fall and initial complaint of hip pain to hospital transfer. In a later interview, the LPN stated he did not know why the resident was not sent to the emergency room sooner and believed it was probably because he did not have a physician’s order, and that he had attempted to manage the pain at the facility. A third resident with muscular dystrophy, obstructive sleep apnea, and dysphagia experienced repeated episodes of low oxygen saturation without timely or consistent intervention. The resident had orders for cough assist every shift for airway management and BIPAP at night, though the BIPAP order was held for a period without documentation explaining why. Oxygen saturation readings showed multiple episodes of hypoxia, including values in the 80s, 70s, 60s, 50s, and as low as the 40s and 30s, often without documented follow-up saturations or immediate treatment. On one occasion, the resident’s sats were 80% and the provider ordered a chest x-ray and labs, but there was no documentation of treatment for low sats for four hours. On several other dates, low sats were recorded with no follow-up readings documented. Staff interviews revealed that CNAs routinely checked sats early in the morning and that this resident’s sats were often in the 70s and 80s at night. A CNA described a night when the resident was hot and cold, calling frequently, and reported difficulty breathing; the CNA found his sats in the 40s and observed him to be blue in the face and pale. She finished assisting him with a urinal and taking out the garbage before informing the nurse, after which oxygen was started and his sats increased above 90%. Another nurse stated that it was not standard to check sats on night shift, but that if sats were low, oxygen should be provided and saturations rechecked, and that sats below 80% should be reported to the DON, physician, and family. The DON reported receiving a call that this resident’s nurse did not act fast enough when the resident had oxygen issues, and administration initiated an investigation, but the administrator stated she did not review the resident’s prior oxygen levels. These events demonstrate repeated failures to promptly assess and treat significant changes in condition, including post-fall injuries and severe hypoxia, in accordance with professional standards, care plans, and resident needs.
Failure to Prevent and Manage Pressure Ulcers for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention and wound care consistent with professional standards for one resident who was admitted with surgical wounds and Moisture Associated Skin Damage (MASD) and later discharged with a Stage 4 pressure ulcer. On admission, documentation noted breakdown on the proximal posterior left lower extremity related to a brace and MASD on the coccyx, but there were no measurements or detailed descriptions of these wounds. The resident was ordered to have a knee immobilizer applied twice daily, but the order did not specify what care was to be provided with the immobilizer, and nursing documentation only showed it was signed off on the MAR. A Braden Scale assessment identified the resident as high risk for pressure sores, and an order for barrier cream to the buttocks/peri-area with each incontinent episode was in place, but there were no signatures on the Treatment Administration Record to show the treatment was provided. Over the course of the stay, multiple new areas of skin breakdown developed, and documentation was inconsistent, incomplete, or missing. Care plans and nursing notes referenced skin impairment to the sacrum, left inner thigh, left great toe, and left posterior calf, but often lacked wound measurements, descriptions, or clear timelines of onset. A new wound to the left posterior calf was first noted by an aide after a shower, and subsequent notes described the area as black with surrounding pink skin, then later as open with yellow slough, moderate yellow drainage, and foul odor. Weekly skin assessments were delayed, with the first one dated months after admission, and when completed, they sometimes documented skin as pink, dry, warm, and intact at locations where other notes and physician documentation indicated the presence of Stage 4 ulcers. Physician notes later identified a Stage 4 ulcer of the left shin, a Stage 4 ulcer on the left hip, and a Stage 4 pressure ulcer of the right hip, in addition to the posterior left lower leg ulcer, but there were no corresponding wound treatment orders for the right or left hip on the MAR. The resident’s left hip surgical site, previously documented as a surgical wound, was later classified as a Stage 4 pressure ulcer without documentation of interventions to prevent further breakdown. There was also no documentation of when sacral skin breakdown developed. The resident had been admitted with a knee immobilizer and subsequently developed a Stage 4 pressure ulcer on the calf where the immobilizer was applied, and the record lacked documentation of interventions used to prevent skin breakdown. When surveyors requested additional information about preventive measures, the Administrator stated there was no documentation beyond what was in the medical record and was unable to provide further information.
Unsafe Supervision, Transportation, and Hot Water Temperatures
Penalty
Summary
The facility did not ensure that the environment remained free of accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. One resident with diagnoses including malignant neoplasm of the large intestine and rectum, muscle weakness, orthostatic hypotension, and moderate protein-calorie malnutrition sustained an unwitnessed fall in the shower room and hit his head after being left unattended. The resident’s record showed that his bathing needs had changed from set-up assist to requiring supervision or partial to moderate assistance, but staff were not aware of the change in condition at the time of the incident. The resident stated that he slipped while taking a shower and that the CNA was not in the room with him. The nurse documented that the resident walked out of the shower room stating he had fallen, was lethargic, had no footwear, and reported that he slipped on water and hit his head. The first responder report documented that the resident was placed in the shower and was last checked on 20 minutes later, and identified contributing factors as being left alone in the shower, no supervision, and no use of the call light. The resident’s care plan addressed fall risk, but the interventions listed before the fall focused on call light use, bed position, and clutter reduction rather than supervision in the shower. A second resident, who had paraplegia, a thoracic spinal injury, and PTSD, was involved in a motor vehicle accident while being transported in the facility van and reported being thrown from the wheelchair because the seatbelt was not secured properly. The resident reported bruising to the ribs and that the driver was drowsy. Records documented injuries and emergency evaluation after the crash, and the facility’s transportation records did not identify which driver transported each resident. The personnel file for the driver contained no documentation of training on safely securing a resident during transportation or education on transporting residents, and the administrator stated that the driver had not received education for driving the facility van. The survey also found resident room sink water temperatures as high as 130.2 degrees, with multiple rooms measuring above 120 degrees. Residents reported that the water could get hot quickly and that staff sometimes had to turn down the hot water. The maintenance director stated that the water heaters were set slightly above 120 degrees, that some rooms were running high, and that mixing valves were on order, while the observed north water heater was set at 130 and had no mixing valve.
Food Storage and Sanitizer Monitoring 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 multiple cups with different liquids in the refrigerator that were not dated, an opened bag of frozen vegetables and an opened bag of buns in the freezer that were not dated, and an opened bag of corndogs that was left open to air. In dry storage, cans of evaporated milk were found past their expiration date. In the resident refrigerator, three sandwiches were found past their use-by date and a pepperoni and cheese snack pack was also expired. On a follow-up kitchen tour, the sanitizer bucket tested at 75 parts per million, and the Dietary Manager stated the required level was 100 parts per million and that surfaces were not being sanitized correctly at 75 parts per million. The same tour also found fresh vegetables, potato salad, and ranch cups inside the refrigerator that were not dated. During interviews, the Dietary Manager acknowledged that drinks in the refrigerator should be dated, the frozen vegetables had been placed in a box without a date, the corndogs should have been closed, expired evaporated milk should be discarded, and items in the resident refrigerator were the responsibility of kitchen staff and should have been thrown out when expired.
Failure to Thoroughly Investigate Abuse and Neglect Allegations
Penalty
Summary
The facility did not have evidence of a thorough investigation in response to allegations of abuse, neglect, exploitation, or mistreatment for 9 of 46 sampled residents. The allegations involved residents with fractures, a motor vehicle accident involving a resident, staff-related allegations concerning care and abuse, a resident who self-harmed, and an allegation of abuse by a spouse. The survey findings identified that the facility could not provide investigation documentation for residents 32, 38, 86, 87, 88, 91, 92, 93, and 95. Resident 86 was admitted and later readmitted with diagnoses including dementia, major depressive disorder, epilepsy, and unsteadiness on feet. The facility reported that the resident sustained a fall, complained of pain, and was found by x-ray to have a fracture, but no investigation was provided to determine whether abuse or neglect occurred. Resident 32, who had paraplegia, a T7-T10 injury, and PTSD, reported that a facility van went off the road and through a fence, that the resident was thrown from the wheelchair because the seatbelt was not secured properly, and that the transportation driver appeared drowsy; the facility had no abuse or neglect investigation documentation for the incident beyond a physical asset report about the vehicle. For the remaining residents, the facility reported allegations but did not provide investigations to determine whether abuse or neglect occurred. Resident 38 reported that a brief was not being changed when asked; resident 87 reported that a CNA hit the resident in the calf and tossed a remote control; resident 88 reported that a CNA hit the resident's hand away during a brief change; resident 91's daughter reported the resident's wound was not being cared for according to physician orders; resident 92 reported a CNA asked inappropriate questions during peri-care; resident 93 was found with blood on the sheets and stated he had intentionally cut himself; and resident 95 reported that her husband hit her arm during an argument while visiting. The Administrator and ADM 2 stated they were unable to locate investigation records for these allegations.
Infection Prevention and Control Program Deficiency
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. For a resident with a feeding tube, staff repeatedly handled the tube without using the full Enhanced Barrier Precautions (EBP) described in the report. The resident was admitted with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, and COPD, and observations showed the feeding tube hanging uncapped around the IV pole or pump when not in use. When CNA 5 and the restorative therapy aide connected the resident to the feeding tube, both were observed wearing gloves but not a gown. For another resident with diagnoses including anorexia, gastrointestinal hemorrhage, abscess of lung with pneumonia, severe sepsis, and a stage three sacral pressure ulcer, EBP signage and supplies were not observed in or outside the room during observations. The resident had orders initiated to ensure EBP were implemented every shift for the catheter and wounds. During interview, RN 7 stated that EBP required a sign on the door and supplies in a hanging caddy within the room, and also stated the resident should be on EBP due to the catheter. However, the room was observed without the sign or supplies at the time of the survey observation. During meal service in the dining room, a CNA assisted a resident with lunch and touched the resident’s food bare handed. The CNA picked up and handed the resident a French dip sandwich, then touched the resident’s plate, lid, wheelchair armrest, and a ham and cheese sandwich bare handed. In interview, another CNA stated staff should never touch a resident’s food bare handed, and the ADON stated staff should not be touching resident food items bare handed and should use utensils instead.
Failure to Properly Justify, Plan, and Document Resident Discharges and Non‑Readmissions
Penalty
Summary
The deficiency involves the facility’s failure to ensure that transfers and discharges were only carried out under permissible conditions, were properly planned and coordinated, and were supported by complete and accurate documentation. For one resident with liver cell carcinoma, heart failure, and a terminal prognosis who had been admitted for comfort management and hospice, the care plan and social services documentation identified a discharge plan of continued LTC with skilled nursing and hospice. Subsequent provider and hospice notes documented clinical decline, including dizziness, severe abdominal pain, weakness, nausea, vomiting, jaundice, and markedly reduced oral intake, without any indication of an upcoming discharge. Despite this, the resident was discharged on the same day a hospice nurse documented further decline, and the first mention of discharge in the record appeared in a hospice chaplain note stating the resident was being asked to leave and did not know where he was going. The facility’s discharge documentation for this resident was incomplete and inaccurate. A Transition of Care/Discharge Summary was printed on the day of discharge using an incorrect discharge date from a prior year and listing the discharge destination as the resident’s RV with home health services, with a goal that he would continue to get stronger with home health. The document omitted any reference to hospice services. All signatures were dated later that afternoon, after the hospice chaplain note, and a nursing progress note recorded that discharge teaching was done and the resident left in a private vehicle with a three‑day supply of medications. Hospice records later showed the resident was actually on LOA and staying at his ex‑wife’s home, and the Social Services Director stated she did not complete the discharge summary, was not involved in the discharge process, and that this lack of involvement was not normal. The Regional Social Work Director determined that staff had reused a prior discharge summary from a previous discharge to the RV, and the hospice director confirmed there was no prior hospice documentation of a planned facility discharge. For a second resident with diffuse TBI, spastic hemiplegia, major depressive disorder, paraplegia, antisocial personality disorder, and suicidal ideations, the facility discharged the resident following episodes of severe aggression and self‑harm behaviors without required physician documentation supporting the discharge and non‑readmission. A nursing progress note described escalating verbal aggression, vulgar language, physical aggression toward staff, attempts to tip the wheelchair, and throwing objects at staff. A discharge summary later characterized the resident as having physical and verbal aggression that staff were unable to manage and a history of suicidal ideation, but there was no physician documentation explaining why the facility was unable to care for the resident, what interventions had been attempted, or why the resident was not readmitted after hospital transfer. Interviews with the Restorative Therapy Aide, ADON, SSD, and Administrator described multiple aggressive incidents, blue‑sheeting to the hospital, suicide attempts, and the facility’s decision not to readmit the resident due to safety concerns, but these details were not supported by corresponding physician documentation in the medical record. Additionally, for the first resident, there was no care plan addressing aggressive behaviors despite multiple progress notes documenting such behaviors, and no documentation of hospice being contacted about behavioral concerns, medication adjustments, or room changes prior to discharge.
Failure to Report Transport Accident Involving Resident Injury
Penalty
Summary
The facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the State Survey Agency. For one sampled resident, Resident 32, the record and interviews showed that the resident was involved in a motor vehicle accident while being transported in the facility van and the incident was not reported to the SSA. Resident 32 was admitted with diagnoses including paraplegia, unspecified injury of T7-T10, and post traumatic stress disorder. During interview, Resident 32 stated that the Transportation Driver was late, drove off the road and through a fence, and that she was thrown from her wheelchair because her seatbelt was not secured properly. She stated that she hit the armrest, sustained bruising to her ribs, and landed on the floor of the van, and that the driver appeared drowsy while driving. Review of the facility abuse investigations found no documentation of the incident and no documentation that it was reported to the SSA. The VPPA stated she investigated the accident but did not report it to the SSA and was unsure whether the DON or Administrator had done so. The Administrator stated that the only documentation available was the physical asset investigation from the VPPA and that it did not appear the incident had been reported to the SSA.
Improper Tube Feeding Handling and Incomplete Formula Labeling
Penalty
Summary
The facility did not ensure that enteral tube feeding services met professional standards of quality for one resident with a PEG tube. Resident 47 was admitted with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, and chronic obstructive pulmonary disease. During observation, a CNA stopped the resident’s tube feeding, disconnected the tube, and took the resident to the bathroom, then later reconnected the tube and restarted the feeding pump. On another observation, a Restorative Therapist Assistant assisted the resident back into bed, connected the feeding tube, and restarted the tube feed. Interviews with nursing staff and facility staff indicated that only nurses were supposed to stop or start tube feedings and connect or disconnect the tube from the resident. The resident’s tube feed labeling was also incomplete. The formula bag was observed labeled only with the date on one occasion and later with a date and time that did not match the observed administration time. Nursing staff stated that tube feeds should be labeled with the date, time of administration, and the initials of the nurse who started the tube feed, while the ADON stated that tube feeds should be labeled when opened but was unsure of the additional required information. Review of Lippincott Nursing Procedures showed that enteral formula containers should be labeled with patient identifiers, formula name, date and time of preparation, date and time hung, route, rate, duration if applicable, initials of who prepared, hung, and checked the formula, expiration date and time, dosing weight if appropriate, and the notation ENTERAL USE ONLY-NOT FOR IV USE.
Medication Given Despite Hold Parameters
Penalty
Summary
The facility did not ensure that each resident's drug regimen was free from unnecessary drugs when Resident 2's furosemide was administered despite physician-ordered hold parameters. Resident 2 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral vascular accident, acute kidney failure, and idiopathic hypotension. The physician ordered furosemide 20 mg by mouth daily with instructions to hold the medication for systolic blood pressure less than 110 or diastolic blood pressure less than 60. The MAR documented that the medication was given on multiple dates when the resident's blood pressure was below the ordered parameters, including readings such as 96/64, 105/65, 106/68, 94/58, 109/85, 105/70, 92/60, 100/69, and 107/68. During interview, RN 1 stated she would hold the medication for blood pressures outside the ordered ranges, and the ADON stated nurses should hold medications based on the parameters documented in the MAR.
Call Light Not Kept Within Reach for Resident With Left-Sided Paralysis
Penalty
Summary
A resident with hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side did not have a call light accessible while in bed. During observation, the resident’s call light was clipped to the top of the bedsheet on the left side, out of reach of the resident’s right hand. The resident stated that staff were supposed to clip the call light to her shirt on the left side so she could reach it, and stated that she had left-sided paralysis. The resident also pointed out signs in the room instructing staff to clip the call light to her left chest. Record review showed prior grievances from the resident’s spouse reporting that the call light had been out of reach during visits, and interviews confirmed that this had occurred at times. The Social Service Director stated she had found times when the call light was not within the resident’s reach, and the CNA and ADON both stated that the call light needed to be within reach because of the resident’s left-sided paralysis and need to use her right arm.
Failure to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility did not provide the necessary housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment for its residents. Specifically, three residents experienced issues with their rooms, including cracked and broken drywall, peeling paint, a door handle that sticks, and a loose toilet. Resident 37 reported having to tape a large hole in the wall, a wobbly toilet, and a door handle that was difficult to use. Despite informing the Maintenance Director, no repairs were made. Resident 24's room had chipped and peeling paint and drywall near the bathroom door. Resident 18's room had peeling paint and drywall near the sink and bathroom, a main door missing pieces of Formica, and chipped cabinets, which were reportedly caused by his roommate's behavior. The Maintenance Director acknowledged being aware of the issues in the residents' rooms but had not addressed them in a timely manner. He mentioned that he was still figuring out what products were required for the repairs and was unsure of the timeframe for completing them. The Administrator was unaware of the multiple repairs needed in Resident 37's room and stated that there was no specific timeframe for maintenance items to be completed unless they were emergent issues. The Administrator also mentioned that repairs related to fixing or painting walls could take up to a week, but nothing should take over a month to be addressed and fixed by maintenance.
Medication Administration Errors
Penalty
Summary
The facility did not ensure that medication error rates were not five percent or greater. During observations of 25 medication opportunities, four medication errors were identified, resulting in a 16% medication error rate. Specifically, for four out of 28 sampled residents, medications that were supposed to be taken at least 30 minutes before meals were given to the residents after they had consumed a meal. The residents involved were identified as 23, 33, 51, and 69. The errors included pantoprazole, gabapentin, metoclopramide, and omeprazole being administered post-meal instead of pre-meal as per the doctor's orders. RN 3 was observed administering these medications incorrectly and acknowledged the errors during interviews. RN 3 stated that resident 23 preferred taking medications after breakfast, and resident 51 was often hard to locate in the mornings, leading to the medication being given after meals. The Director of Nursing (DON) confirmed that there was no documentation of residents' medication preferences in the medical records and emphasized that all nurses need to follow the doctor's orders for medication administration. The DON stated that medications ordered to be given before meals must be administered before meals, and if this is not feasible, the doctor's orders need to be updated accordingly.
Failure to Evaluate Resident for Self-Administration of Medications
Penalty
Summary
The facility did not ensure that the interdisciplinary team had evaluated and determined that a resident's right to self-administer medications was clinically appropriate. Specifically, medications were found at the bedside of a resident who had not been assessed for self-administration. The resident, identified as having severe cognitive impairment and multiple diagnoses including polyneuropathy, dementia, and major depressive disorder, had Tums at their bedside, which they took as needed without proper evaluation or physician's order. Interviews with staff, including an LPN, RN, and the DON, revealed that the facility's policy required a self-administration assessment and a physician's order for residents to keep medications at their bedside. The staff confirmed that resident 43 had not been assessed for self-administration and was not authorized to have medications at their bedside. The DON emphasized that the purpose of the assessment was to ensure the resident's safety in self-administering medications, and resident 43 was not among those permitted to do so.
Inaccurate Resident Assessment for Insulin Administration
Penalty
Summary
The facility did not ensure that the resident assessment accurately reflected the resident's status. Specifically, for one resident, the facility coded the resident as having received insulin during the seven-day Minimum Data Set (MDS) observation period when the resident had not received any insulin. The resident was admitted with diagnoses including infection and inflammatory reaction due to internal left knee prosthesis, type 2 diabetes mellitus with hyperglycemia, and type 2 diabetes mellitus without complications. A review of the resident's medical record and Medication Administration Record showed no orders or documentation of insulin administration since admission. The MDS Coordinator confirmed that the MDS assessment had been miscoded.
Delay in Treatment for Respiratory Illness
Penalty
Summary
The facility failed to ensure that a resident with a respiratory illness received timely treatment and care in accordance with professional standards of practice and the resident's comprehensive person-centered care plan. Resident 43, who had severe cognitive impairment and multiple diagnoses including asthma, experienced a delay in receiving appropriate medical intervention for their respiratory symptoms. Despite the resident's family member notifying the Director of Nursing (DON) about the resident's condition over the weekend, the resident was only given nasal spray and Mucinex until the physician assistant saw them on Monday and ordered a chest x-ray, breathing treatment, and oxygen therapy. The medical record review revealed that the resident's oxygen saturation was documented to be 89% on one occasion and 80% on another, yet no immediate interventions were put in place to address these low oxygen levels. Interviews with the nursing staff indicated that although the resident had been complaining of respiratory symptoms and had received some as-needed medications, there was a lack of timely and appropriate response to the resident's deteriorating condition. The DON acknowledged that the nurses should have followed standing orders for oxygen and notified the physician and DON about the resident's low oxygen saturation. The deficiency was further highlighted by the fact that the resident's condition was not adequately monitored or addressed over the weekend, leading to a delay in receiving necessary medical treatment. The DON and nursing staff provided inconsistent accounts of the events and actions taken, indicating a breakdown in communication and adherence to protocols. The resident's family member expressed concern that the resident's condition should have been treated sooner, underscoring the facility's failure to provide timely and appropriate care.
Failure to Provide Recommended Restorative Nursing Services for Resident with Limited ROM
Penalty
Summary
The facility did not ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and prevent further decline. Specifically, for one resident with chronic inflammatory demyelinating polyneuritis, diabetes mellitus, difficulty walking, hypertension, chronic pain syndrome, and muscle weakness, the facility failed to provide restorative nursing services recommended by physical therapy. The resident expressed a desire for physical or occupational therapy due to perceived loss of mobility and ROM, but was informed that his insurance would not cover these services and was not offered alternative therapies or exercises by the facility. The resident's care plan included encouraging PT/OT services and assisting with ADL tasks. An orthopedic note and a physical therapy evaluation recommended PT for the resident's right knee and participation in the restorative nursing program for upper and lower extremity ROM. However, the Director of Rehab was unaware of the therapy needs, and the Minimum Data Set Coordinator could not locate a referral for the restorative nursing program. The Director of Nursing acknowledged the resident's ongoing ROM issues but was unsure if there had been a decline since admission. The Administrator was also unaware of the resident's desire for therapy services and believed the resident was already receiving restorative nursing assistance.
Failure to Provide Adequate Nutritional Supplements
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status. Specifically, a resident with a recommendation for Liquacel twice a day for wound healing and increased protein needs had the Liquacel order implemented daily, and the Liquacel was unavailable for four administrations. The resident had multiple diagnoses, including infection and inflammatory reaction due to internal left knee prosthesis, type 2 diabetes mellitus, and peripheral vascular disease. The care plan included offering supplements and double portions, providing diet and snacks as prescribed, and weight monitoring, among other interventions. The resident's medical record indicated that the resident was at moderate risk for malnutrition due to poor medical history, poor mobility, and inadequate oral intake. Despite the dietary recommendation for Liquacel 30 mL twice a day, the order was implemented as once a day. The resident expressed concerns about not getting enough protein and the dietary recommendations were not consistently followed. The April and May Medication Administration Records showed that the Liquacel was not administered on four occasions due to unavailability. Interviews with staff revealed that there were issues with ordering and stocking the Liquacel. The Registered Nurse stated that the Liquacel was ordered with over-the-counter medications and that Central Supply was responsible for ordering it. The Transportation Director, who had just started working in Central Supply, confirmed that the Liquacel was ordered weekly and that there were sometimes delays in receiving items. The Registered Dietician and Dietary Director confirmed that the Liquacel was recommended for wound healing and that the order should have been twice a day. The Director of Nursing stated that dietary recommendations were discussed in meetings and that the Unit Manager was responsible for inputting the orders.
Failure to Provide Prescribed Supplement
Penalty
Summary
The facility failed to provide routine and emergency drugs and biologicals to a resident, specifically a protein supplement necessary for wound healing. Resident 18, who had multiple diagnoses including infection due to a knee prosthesis, diabetes, and muscle weakness, was not administered Liquacel as ordered by the physician. The resident's medical record indicated that the supplement was recommended by the dietitian and agreed upon by the resident, but it was not available on several occasions, leading to missed doses on 4/25/24, 5/5/24, 5/6/24, and 5/7/24. Interviews with staff revealed a breakdown in the ordering and stocking process for the supplement. The Registered Nurse (RN) responsible for medication refills stated that the Liquacel was ordered through Central Supply and should have been available in the medication room. However, the Transportation Director, who had recently taken over central supply duties, indicated that she had not yet ordered Liquacel and was unaware of its shortage until it was too late. The process for ordering over-the-counter medications involved a weekly review and order, which led to delays in obtaining the necessary supplement. Further interviews with the Registered Dietician (RD) and the Director of Nursing (DON) confirmed that the dietary recommendations were communicated during Nutrition At Risk (NAR) meetings and should have been followed up with appropriate orders. Despite these procedures, the supplement was not available when needed, and the resident was given an alternative (Metamucil) when the Liquacel was out of stock. This deficiency highlights a failure in the facility's system to ensure timely availability of prescribed supplements for resident care.
Failure to Act on Pharmacist's Medication Recommendation
Penalty
Summary
The facility did not ensure that the pharmacist's recommendation to discontinue atorvastatin during daptomycin therapy was acted upon in a timely manner. Specifically, for one resident, the recommendation to discontinue atorvastatin to avoid potential myopathy and rhabdomyolysis was accepted by the Physician Assistant on 3/15/24 but was not implemented until 4/2/24. During this period, the resident continued to receive atorvastatin daily while also being administered daptomycin, contrary to the pharmacist's recommendation. The delay in implementing the recommendation was attributed to the Director of Nursing (DON) being on vacation and the process of handling the pharmacist's recommendations being disrupted. The DON stated that the pharmacist's reports were usually reviewed and acted upon within 24 to 48 hours, but due to her absence, the recommendations were not updated and noted in a timely manner. This lapse resulted in the resident receiving potentially harmful medication concurrently for an extended period.
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 51 citations issued within 25 miles in the last 12 months — including the 1 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 Logan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Logan Regional Hospital Transitional Care Unit | 0.2 mi | ★★★★★ | 2 | 0 |
| Maple Springs Senior Living | 0.9 mi | ★★★★★ | 12 | 0 |
| Sunshine Terrace Skilled Nursing | 1.8 mi | ★★★★★ | 16 | 1 |
| Monument Healthcare Brigham City | 18.9 mi | ★★★★★ | 1 | 0 |
| Monument Healthcare Pioneer Trail | 21 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Rocky Mountain Care - Logan.
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 July 2026) and official state health department websites.