Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rocky Mountain Care - The Lodge during CMS and state inspections, most recent first.
A resident with foot wounds had inconsistent skin documentation and a right toe wound was not evaluated or treated under an order when first identified. Another resident with bilateral AKA stumps received wound care to the right stump despite only left stump orders, and hospice wound notes lacked wound details. Two other residents had changes in condition, including decline before death and transfer to the hospital, but the chart lacked the expected nursing documentation and assessments.
Two residents did not receive ordered nutrition support or therapeutic diets. One resident with severe malnutrition and an NG tube went several days without tube feeding while oral intake was inconsistent, and the resident lost significant weight. Another resident with ESRD and elevated potassium was not provided low potassium foods when the dialysis center ordered it, and the chart reflected a carbohydrate-controlled diet instead of the ordered renal diet.
Dishmachine Temperatures Below Required Sanitizing Levels: The facility’s dishmachine was observed running below the manufacturer’s required sanitizing temperatures, with wash, rinse, and final rinse readings not meeting the posted standards. Clean cups, plates, domes, mugs, and bowls were removed from the machine and placed with clean dishes while the DM and another staff member confirmed the temperatures were below the required levels and that the thermometer available for checking the machine was not working.
The facility failed to ensure routine and emergency medications were available for administration for multiple residents. One resident with MS had difficulty obtaining Kesimpta injections, with a scheduled dose not administered and no explanation documented. Another resident had Clonidine, Hydralazine, and Ferrous Fumarate documented as not available, and a third resident had potassium chloride, topiramate, Myrbetriq, and duloxetine documented as not available or on order.
Failure to timely report alleged abuse or neglect. A resident with a history of falls, fracture, muscle weakness, osteoporosis, and major depressive disorder sustained a witnessed fall and was sent to the hospital, where a sacral fracture was identified. The facility did not report the allegation to the SSA until 5 days later, and the DON and ADM stated it should have been reported within 24 hours.
A resident with encephalopathy, malnutrition, anxiety disorder, and failure to thrive was observed with strong body odor and in the same clothing on consecutive days. Although the MDS showed he needed set up or clean up help with bathing and the care plan addressed ADL needs and refusals of care, the CNA record showed showers were scheduled but often not completed, with multiple missed or refused showers and staff reporting he sometimes smelled and received showers only about once a week.
A resident with multiple sclerosis, chronic pain, and decreased sensation in her feet was given hot packs after her heated blanket was removed. Staff microwaved the packs but did not determine the temperature before applying them, relying on the CNA’s ability to touch the pack and on the resident to say when it should be removed. The DON was unaware the packs were being heated in the microwave, and the ADM stated the facility did not allow microwave-heated reusable packs because the temperature could not be known before skin contact.
Missing Post-Dialysis Assessments for Resident Receiving Hemodialysis: A resident with ESRD and dependence on renal dialysis had orders for dialysis 3 times weekly, a 1000 mL fluid restriction, and monitoring of the dialysis site every shift. Record review showed the facility did not complete post-dialysis assessments after each dialysis session, and the DON confirmed the assessments were not completed.
Medication administration records showed that one resident had omitted doses, held Hydralazine, and missed Insulin Lispro doses despite blood sugar values meeting ordered sliding-scale parameters, with no documented reasons in the progress notes. A second resident received Bumetanide and Metoprolol without documented BP readings. The DON confirmed the undocumented omissions and that one Hydralazine hold should not have occurred.
A resident with multiple psychiatric diagnoses had physician-ordered CBC and UA testing cancelled when the CBC specimen clotted and the UA was never received, but the tests were not redrawn. The DON stated there was no notification from the lab that the tests were cancelled, and that cancelled lab results were normally called to the nurses station.
Complete, dated lab records were not maintained in the clinical records for two residents. One resident with ESRD, renal dialysis dependence, kidney transplant rejection, pulmonary HTN, CHF, and HTN had ordered lipid panel and A1c results missing from the chart. Another resident with hemiplegia, cerebral infarction, morbid obesity, DM2, and foot injuries had ordered CMP, BMP, and A1c results absent from the record, and the DON stated the results had been requested from the lab.
A resident with hemiplegia/hemiparesis, cerebral infarction, morbid obesity, DM2, a right toe fracture, and a non-pressure injury of the left foot had physician-ordered x-rays of both knees, but the facility did not obtain or document the right knee x-ray results. The DON later received the left knee x-ray, but the right knee results were still unavailable.
Infection control was not maintained for two residents. An RN removed an oxycodone tablet from a blister pack, then placed it back after the resident refused it. During wound care for another resident with bilateral AKA stumps and a left stump wound, hand hygiene was not performed after glove changes, and the same gauze pad was reused multiple times to clean the wound bed. The DON and ADON stated these actions were not consistent with proper practice.
A resident with a recent surgical ankle repair did not receive wound care as ordered on two occasions, with documentation showing the resident was unavailable or could not be located. Required follow-up actions, such as passing the order to the next shift and notifying the physician, were not completed according to facility policy.
A resident with diabetes and hypertension did not receive multiple scheduled doses of antibiotics, antihypertensives, and insulin as ordered, with missed doses marked as unavailable or the resident being unavailable. Required follow-up actions, such as physician notification and obtaining alternative orders, were not completed according to facility policy.
Two residents with cognitive impairments eloped from the facility due to inadequate supervision and ineffective alarm systems. One resident, with a history of cerebral infarction and Wernicke's encephalopathy, was struck by a car after eloping, while another resident with severe cognitive impairment was found by emergency services after leaving the facility. Staff interviews revealed that alarms were not audible throughout the building, contributing to the residents' ability to elope unnoticed.
The facility failed to provide mandatory training on dementia management and abuse prevention for several CNAs and an LPN. Despite policy requirements, there was no documentation of training completion, and staff were assigned shifts without it. The CNA Coordinator was unaware of her responsibility for staff education due to a lack of communication following a staffing change.
A resident with moderate cognitive impairment and incontinence was found lying in bowel movement and urine, leading to a grievance filed by a family member. The facility failed to document steps taken to investigate the grievance or confirm the concern. The grievance was not fully investigated, and it was unclear if the resident received incontinence care, as revealed in interviews with facility staff.
A resident with severe cognitive impairment and behavioral issues was involved in two incidents of physical abuse against other residents. In the first incident, the resident pulled another resident's arm, causing them to fall and sustain injuries. In the second incident, the resident slapped another resident twice after an argument. Both incidents highlight the facility's failure to adequately supervise and manage residents with known behavioral issues.
The facility failed to protect the personal health information (PHI) of two residents by displaying it on whiteboards in their rooms, visible to others. Staff, including a CNA Coordinator and the DON, confirmed this was a HIPAA violation. The residents' care plans did not indicate approval for such displays, and both residents had cognitive impairments.
The facility did not perform a criminal background check for a CNA before employment, violating its policy on abuse prevention. The policy requires screening for abuse history through background checks. The CNA was hired without this check, as confirmed by the Executive Director and DON, who stated the corporate office was responsible but did not complete it.
Failure to document and treat wounds and changes in condition
Penalty
Summary
The facility did not ensure that residents received treatment and care in accordance with orders, the comprehensive care plan, and resident choices. For one resident with hemiplegia, cerebral infarction, morbid obesity, diabetes, and foot injuries, staff observed open wounds on both second toes with dried blood, but the record showed inconsistent documentation of the wound location and repeated skin checks stating the skin issue had not been evaluated. The resident had a physician order for wound care to the left second toe, yet the right second toe wound was not evaluated or treated under an order when it was identified. The ADON stated she was not aware of the right second toe wound, confirmed it had not been evaluated by her or the provider, and later assessed the wound and entered orders after the fact. For another resident with multiple sclerosis, diabetes, bilateral above-the-knee amputations, infection of the left amputation stump, and chronic pain, the record showed wound care documentation that did not identify wound locations or characteristics, and hospice notes documented refusal of wound assessment or wound care on multiple occasions. The resident had an order for the left stump, but nursing staff were observed providing wound care to the right stump even though RN 4 stated there were only orders for the left stump. RN 4 removed the dressing from the right stump, cleansed it, and applied a new bordered foam dressing. The RN stated the right stump was newly closed and that she would notify the wound nurse to assess it and place a treatment order. The ADON stated hospice was in charge of wound care, but also stated that all dressings applied should have an order and that a new wound should be documented somewhere. The facility also did not document change in condition for two residents. One resident with Parkinson's disease, dementia, malnutrition, epilepsy, and failure to thrive had nursing notes showing hospice was notified of worsening vital signs and comfort medications were continued, followed by a note that oxygen saturation had dropped to 72% and the resident was transitioning, but there were no other nursing progress notes or assessments documenting the decline or death. Another resident with encephalopathy, acute respiratory failure with hypoxia, diabetes, ovarian cancer, and severe sepsis refused NG medications because of nausea and vomiting and was described as very lethargic before being transferred to the hospital, but there were no further progress notes documenting the change in condition. Interviews with nursing staff and the DON confirmed that change in condition documentation, notification, and assessment should have been completed for these events.
Failure to Maintain Ordered Nutrition Support and Therapeutic Diets
Penalty
Summary
Resident 13, who was admitted with severe protein-calorie malnutrition, chronic pancreatitis, dysphagia, and other diagnoses, had an NG tube and tube feeding ordered for nutritional support. The record showed the tube feeding order was discontinued, and the resident then went without tube feeding for several days while oral intake was inconsistent and often poor, including refusals and intake as low as 0-25% on multiple meals. During this period, the resident was observed with tube feeding supplies in the room but not connected to the feed, and the resident stated the tube feed usually ran all the time and that she was trying to eat breakfast but remained below weight. The resident’s weight declined from 106.2 lbs to 101.6 lbs in five days, then to 93.4 lbs, reflecting a 12.05% total loss over that short period. The nutrition evaluation documented an ideal weight range of 119 to 130 lbs, but the macronutrients were not calculated at the initial evaluation, and the Med Pass intervention recommended for low body mass index and low intake was not implemented. The DON stated the tube feed had been stopped because the hospital order was completed, and the RD stated she was not aware the resident had been without tube feeding for 5 to 6 days and did not think it was okay for the resident to go without the tube feed for that long. Resident 6 had end stage renal disease, diabetes, and dialysis dependence, and a nutrition evaluation documented a high potassium level of 5.3 mmol/L. Later, the resident had a critical potassium of 6.0 mmol/L, and staff notes indicated dialysis was received and repeat lab testing was ordered but refused. The dietary record and meal ticket reflected a carbohydrate-controlled diet with fluid restriction, but the DM stated the meal ticket should have indicated low potassium foods if required, and the RD stated she had not been able to contact the dialysis center RD and was not provided information that the resident’s potassium was elevated. The RD later stated the resident should have been served the diet according to the physician’s order, and the RNC stated the resident had previously been on a renal diet before hospitalization.
Dishmachine Temperatures Below Required Sanitizing Levels
Penalty
Summary
The facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety because the dishmachine temperatures were below the manufacturer’s required temperatures for sanitizing dishes. On 6/1/26 at 9:45 AM, an observation of the dishmachine showed wash temperatures of 160 and rinse temperatures of 150 for three loads of dishes, and additional cycles with wash at 160, rinse at 150, final rinse at 135; wash at 160, rinse at 155, final rinse at 140; and wash at 165, rinse at 155, final rinse at 130. Cups, plates, domes, mugs, and bowls were observed being removed from the dishmachine baskets and placed with the clean dishes. During interview, [NAME] 1 stated the wash temperature needed to be above 150, rinse above 160, and final rinse above 180, and said those temperatures were listed directly on the dishmachine. The manufacturer’s posted temperatures on the high-temperature dishmachine were observed to be wash above 150, rinse above 160, and final rinse above 180. The Dietary Manager observed the machine and stated the wash was 165, the rinse was 155, and the final rinse was 130. The DM also stated staff could use a thermometer to check temperatures, but the thermometer obtained had dead batteries and did not work. In a later interview, the DM stated dishes needed to be washed in the 3-compartment sink until the dishmachine company could look at the machine, and stated staff should have stopped washing dishes and notified the DM when the temperatures were not reaching the required level.
Medications Not Available for Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when routine and emergency medications were not available for administration for 3 of 36 sampled residents. The report identified that Resident 29, who had multiple sclerosis, protein calorie malnutrition, chronic pain syndrome, and major depressive disorder, experienced problems with obtaining her Kesimpta injections. The resident stated the nurses struggled to get her MS medication every month and that it was due every 28 days. The MAR showed the April 2026 dose was not administered, and there was no documentation explaining why it was not given. For Resident 6, who had diagnoses including kidney transplant rejection, end stage renal disease, dependence on renal dialysis, pulmonary hypertension, congestive heart failure, and hypertension, the May 2026 MAR documented that Clonidine, Hydralazine, and Ferrous Fumarate were not available for administration on separate dates. The DON stated that a blank area on the MAR usually meant the medication was unavailable and that code 11 indicated the medication was not available for administration. The DON also stated refill requests should be sent 7 or 8 days before the last dose so medications would not run out. For Resident 39, who had major depressive disorder, PTSD, borderline personality disorder, generalized anxiety disorder, cognitive communication deficit, and depression, the record documented multiple medications as not available, including potassium chloride, topiramate, Myrbetriq, and duloxetine. Nursing notes stated the medications were currently not available or on order, with pharmacy stating delivery would occur later or the provider being notified. An RN stated that if a medication was needed immediately, he would use the emergency medication cart, and if it was not available there, he would contact the DON or NP.
Failure to Timely Report Alleged Abuse or Neglect
Penalty
Summary
The facility did not ensure that all alleged violations involving abuse and neglect were reported to the State Survey Agency (SSA). For Resident 76, who was admitted and later readmitted with diagnoses including fall with fracture, major depressive disorder, muscle weakness, and osteoporosis, the facility reported that the resident sustained a witnessed fall on 12/25/25 and was transferred to the hospital, where a sacral fracture was identified. The facility did not report the allegation of abuse or neglect to the SSA until 12/31/25, five days after becoming aware of the broken sacrum. During interview, the DON stated the facility became aware of the fracture on 12/25/26 and did not know why it was not reported sooner, and the Administrator stated he did not know why it was not reported within 24 hours and that it should have been reported on 12/25/25.
Failure to Maintain Bathing and Hygiene Assistance
Penalty
Summary
Resident 57, who was admitted with diagnoses including encephalopathy, protein-calorie malnutrition, anxiety disorder, and failure to thrive, was found to have strong body odor during observations on 6/2/26 and again on 6/3/26, when he was seen in the same clothing from the prior day. His annual MDS indicated he needed set up or clean up assistance with bathing, and his care plan identified altered ADL function related to muscle weakness, with interventions to meet ADL needs each day and assist with ADL tasks. A separate care plan also documented behavioral symptoms including refusals of care. The CNA task record showed showers were scheduled for Tuesday, Thursday, and Saturday evenings, but Resident 57 was showered only on 5/5/26, 5/23/26, and 5/26/26. The record also showed he refused a shower on 6/3/26 and was marked unavailable on multiple scheduled shower dates in May. Staff interviews stated he sometimes refused showers, sometimes received them about once a week, and sometimes had body odor. The DON stated that if a resident refused a shower, a refusal sheet was completed, and if a resident was cognitively impaired and starting to smell, staff should make multiple attempts to offer shower assistance.
Inadequate supervision of heated packs for a resident with decreased foot sensation
Penalty
Summary
The facility did not ensure adequate supervision and assistance devices were used to prevent accidents for Resident 29, who was admitted with diagnoses including multiple sclerosis, protein-calorie malnutrition, chronic pain syndrome, and major depressive disorder. A quarterly MDS assessment indicated the resident was cognitively intact. During an interview, Resident 29 stated her feet were really cold because of restricted blood flow, that she had loss of sensation in her feet but could still feel hot and cold, and that her heated blanket had been removed from her room. She also stated staff provided hot packs in place of the heated blanket, and homemade hot packs were observed on her table. Staff interviews showed the hot packs were being microwaved for 45 seconds before use, but the CNA did not obtain a temperature before applying them and relied on being able to touch the hot pack herself. The CNA stated she asked Resident 29 how the hot pack felt, but was not sure how much feeling the resident had in her feet, and the resident let staff know when to remove it. The DON stated Resident 29's feeling in her feet was minimal and that she was not aware hot packs were being heated in the microwave. The Administrator stated the facility did not allow heating pads, heated blankets, or reusable heat packs warmed in the microwave because the temperature could not be known before placement on the skin and the items could cause burns.
Missing Post-Dialysis Assessments for Resident Receiving Hemodialysis
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required hemodialysis. Resident 6 had diagnoses including kidney transplant rejection, end stage renal disease, and dependence on renal dialysis, and was ordered to receive dialysis three times weekly on Monday, Wednesday, and Friday. The resident also had orders for a pre-dialysis communication form to be sent with the resident every dialysis day, a post-dialysis communication form to be returned to the facility and scanned every dialysis day, a 1000 mL fluid restriction, and monitoring of the dialysis site for bleeding and signs or symptoms of infection every shift. Record review showed that in May 2026 the facility documented the fluid restriction, returned pre- and post-dialysis forms, and recorded dry weight from dialysis except on two dates, but post-dialysis assessments were not completed for each dialysis appointment. The DON stated that the post-dialysis form should document the resident's weight and any medications or labs from dialysis, and that the floor nurse should complete a post-dialysis assessment after each dialysis visit to monitor the resident's condition, especially given her fragile diabetes. The DON later confirmed that the post-dialysis assessments were not completed for the resident.
Medication omissions and undocumented holds/administrations
Penalty
Summary
The facility did not ensure that residents’ drug regimens were free from unnecessary drugs because medications were not administered as ordered and there was no documentation for omissions or holds. One resident with diagnoses including kidney transplant rejection, end stage renal disease, dialysis dependence, pulmonary hypertension, congestive heart failure, and hypertension had orders for Hydralazine, Clonidine, Insulin Lispro sliding scale, and Pregabalin. The MAR showed Clonidine was coded as not given with no progress note documenting the reason, Pregabalin was coded as not given for several days with no documented reason, Hydralazine was coded as held without a documented blood pressure reading or reason, and Insulin Lispro was held on multiple occasions when the blood sugar values met the ordered parameters for administration. The DON confirmed the omissions and stated that Hydralazine should have been administered on one of the dates it was held. A second resident with multiple sclerosis, type 2 diabetes mellitus, bilateral above-the-knee amputations, infection of a left amputation stump, and chronic pain had orders for Metoprolol Succinate ER with hold parameters for low systolic blood pressure or low heart rate, and Bumetanide. The May 2026 MAR showed Bumetanide and Metoprolol were administered on several occasions without a documented blood pressure reading. During interview, the DON stated that vital signs should be documented and that the MAR allowed nurses to document the order as completed even when vital signs were not listed.
Failure to Obtain Cancelled Lab Tests
Penalty
Summary
The facility failed to provide or obtain laboratory services needed for Resident 39, who was admitted with diagnoses including major depressive disorder, post traumatic stress disorder, borderline personality disorder, generalized anxiety disorder, cognitive communication deficit, and depression. A physician ordered a CBC, comprehensive metabolic panel, and UA with culture and sensitivity on 5/22/26, and later ordered the CBC to be re-drawn the same day and the UA culture and sensitivity on 5/25/26. Review of the lab reports showed the CBC specimen clotted and the UA was cancelled because it was never received, but the CBC and UA were not redrawn. During an interview on 6/4/26, the DON stated there was no notification from the laboratory that Resident 39's UA or CBC had been cancelled, that the tests were not redrawn, and that when lab results were cancelled the lab called the nurses station.
Failure to File Ordered Laboratory Results in Resident Records
Penalty
Summary
Complete, dated laboratory records were not kept in the residents' clinical records for 2 of 36 sampled residents. Resident 6 was admitted and later re-admitted with diagnoses including kidney transplant rejection, end stage renal disease, dependence on renal dialysis, pulmonary hypertension, congestive heart failure, and hypertension. On 3/9/26, a physician ordered a lipid panel and hemoglobin A1c, but no laboratory results for those tests could be found in the resident's medical record. Resident 9 was admitted with diagnoses including hemiplegia and hemiparesis, cerebral infarction, morbid obesity, type 2 diabetes mellitus, fracture of the right toe, and a non-pressure injury of the left foot. The resident had physician orders for a CMP on 10/22/25 and 10/29/25, and for a BMP and hemoglobin A1c on 11/12/25, but no documentation of the ordered laboratory results was found in the medical record. During interview, the DON stated that the lab results were requested from the laboratory and that the results would be uploaded into the residents' records.
Missing Ordered Knee X-Ray Results
Penalty
Summary
The facility did not ensure that radiology and diagnostic services were obtained to meet resident needs because it failed to obtain the ordered x-ray results for Resident 9's right knee. Resident 9 was admitted with diagnoses including hemiplegia and hemiparesis, cerebral infarction, morbid obesity, type 2 diabetes mellitus, fracture of the right toe, and a non-pressure injury of the left foot. On 2/6/26, the physician ordered x-rays of both the left and right knee, but no documentation of the right knee x-ray results was found in the medical record. On 6/2/26 at 2:44 PM, the DON emailed copies of the left knee x-ray, and was informed that the right knee x-ray results were still not available; no results for the right knee x-ray were provided.
Infection Control Lapses During Medication Handling and Wound Care
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 diseases and infections. For one resident with diagnoses including osteomyelitis, severe sepsis with septic shock, and stage 2 pressure ulcers, a nurse removed an oxycodone tablet from a blister pack, the resident refused it, and the nurse placed the tablet back into the blister cell and folded the paper over it. The Director of Nursing stated that if a resident refused a narcotic medication that had been removed from a blister cell, the nurse should dispose of it with another nurse and document it in the narcotic log, and stated that placing medication back into a blister cell created infection control concerns and made it impossible to be certain the correct medication was returned. For another resident with multiple sclerosis, type 2 diabetes mellitus, bilateral above-the-knee amputations, infection of the left amputation stump, and chronic pain, wound care was observed on both stumps even though the documented order was for the left stump only. During the dressing change, the nurse performed hand hygiene at the start and donned gloves and a gown, but after doffing and donning new gloves, no hand hygiene was performed. The nurse cleaned the left stump wound bed with a saline-moistened gauze pad and then folded the same gauze pad over itself and wiped the wound bed two more times with the same pad. The ADON, who was also the wound care nurse, stated that staff should perform hand hygiene before wound care, at glove changes, and after doffing gloves, and that a new gauze pad should be obtained when cleaning the same area multiple times.
Missed Wound Care Orders and Lack of Follow-Up
Penalty
Summary
A deficiency was identified when a resident who was admitted following surgical repair of a fractured ankle did not receive wound care as ordered by the physician. The resident had wound care orders specifying treatment to the right ankle and later to the right foot, with instructions on frequency and method. On two separate occasions, the wound care was not completed as scheduled. Documentation in the Medication Administration Record (MAR) indicated that on one occasion, the resident was marked as unavailable, and on another, the nurse noted being unable to locate the resident while they were not busy. The facility's Wound Treatment Management Policy requires that wound treatments be provided according to physician orders, including frequency and method, and that if a resident is unavailable, the order should be passed to the next shift and the physician notified. However, follow-up actions for the missed wound care orders were not carried out in accordance with this policy, as there was no evidence that the orders were passed on or that the physician was notified after the missed treatments.
Failure to Prevent Significant Medication Errors Due to Missed Doses
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by multiple missed doses of prescribed medications. The resident, who had diagnoses including type 1 diabetes mellitus and hypertension, was scheduled to receive several critical medications such as antihypertensives (Amlodipine and Losartan-Hydrochlorothiazide), an antibiotic (Ciprofloxacin), and insulins (Lispro and Lantus). Review of the Medication Administration Records (MAR) for October and November 2024 revealed that several doses of these medications were not administered as ordered. Specifically, the resident missed 4 of 13 doses of Ciprofloxacin, 3 of 30 doses of Amlodipine, 5 of 30 doses of once-daily Lispro, 4 of 30 doses of pre-meal and bedtime Lispro, 5 of 30 doses of Lantus, and 2 of 30 doses of Losartan-Hydrochlorothiazide. The missed doses were documented as due to medication unavailability or the resident being unavailable, but there was no evidence that staff followed the facility's policy requiring physician notification and obtaining alternative treatment orders when medications were not administered. Further, administrative staff were unable to provide an explanation for why these medications were repeatedly marked as unavailable, and acknowledged that such documentation should not occur without appropriate follow-up actions.
Inadequate Supervision and Alarm System Failures Lead to Resident Elopements
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents related to elopement for two residents. Resident #59, who had a history of cerebral infarction, aphasia, dysphagia, and Wernicke's encephalopathy, was admitted to the facility and was identified as an elopement risk. Despite having a departure alert system in place, Resident #59 managed to elope from the facility multiple times. On one occasion, the resident pushed through the front door, exited the building, and was struck by a car while pushing a wheelchair. The facility's alarms were reportedly not audible throughout the building, and staff were not always aware of the resident's whereabouts, leading to the resident's elopement and subsequent accident. Resident #38, who had severe cognitive impairment and a history of wandering, also eloped from the facility. The resident was admitted with diagnoses including metabolic encephalopathy and generalized anxiety disorder. Despite being equipped with a wander/elopement alarm, Resident #38 managed to leave the facility unnoticed. The resident was later found by emergency services with minor injuries. The facility's alarm system was again noted to be ineffective, as staff did not hear the alarms, and the resident was able to exit the building without detection. Interviews with staff revealed inconsistencies in the effectiveness of the alarm systems and the staff's ability to hear them. Some staff members reported that the alarms were faint and could not be heard from certain areas of the facility. Additionally, there were reports of inadequate training and communication regarding elopement risks and the use of the alarm systems. These deficiencies in supervision and alarm system effectiveness contributed to the residents' ability to elope and the subsequent accidents.
Failure to Provide Mandatory Training for Staff
Penalty
Summary
The facility failed to provide mandatory training related to dementia management and resident abuse prevention for four out of six sampled employees, including CNAs and an LPN. The facility's policy required that training be completed before staff independently provided services to residents, annually, and as necessary based on the facility assessment. However, a review of personnel files revealed no documentation of such training for the employees in question. Interviews with the Director of Nursing (DON) and the Executive Director (ED) confirmed that the orientation checklists were not completed for these staff members, and they were assigned to work shifts without the required training. The deficiency was further compounded by a lack of clarity regarding responsibility for ensuring staff education. The CNA Coordinator, who was supposed to ensure the training was provided, stated that she was not informed of her new responsibilities after the departure of a human resources staff member previously responsible for new employee education. Additionally, the CNA Coordinator did not have access to employee education records, leaving her unaware of whether the training had been completed. This lack of communication and oversight resulted in the failure to provide essential training to staff members before they worked independently.
Facility Fails to Investigate Grievance of Resident Found in Soiled Condition
Penalty
Summary
The facility failed to adequately address a grievance filed by a family member of a resident who was found lying in bowel movement and urine. The grievance was filed on the morning of October 16, 2023, but the facility was unable to provide documentation of the steps taken to investigate the concern or information regarding whether the facility was able to confirm the concern. The facility's policy requires the Grievance Official to oversee the grievance process, including receiving and tracking grievances, leading investigations, and issuing written grievance decisions. The resident involved was admitted to the facility on September 7, 2023, with diagnoses including type two diabetes mellitus, unspecified dementia, muscle weakness, unspecified lack of coordination, and a need for assistance with personal care. The resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment, and was dependent on staff for toileting hygiene, being always incontinent of urine and bowel movement. The resident's care plan directed staff to keep the call light in reach, assist with toileting, and provide incontinence care after each episode of incontinence. The facility's Concern Log noted the grievance was filed by the Social Services Director (SSD) and marked as resolved. However, the Concern Form did not reflect any steps taken to investigate the concern or indicate if the concern was confirmed. Interviews with the Executive Director (ED), SSD, and Director of Nursing (DON) revealed that the grievance was not fully investigated, and it was unclear if the resident had been provided incontinence care. The ED acknowledged that the grievance should have been better investigated, and the DON stated that the nursing department should have been made aware to investigate the concern.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, specifically involving Resident #228, who had a history of severe cognitive impairment and behavioral issues. Resident #228 was involved in two separate incidents of physical abuse against other residents. The first incident involved Resident #48, who also had severe cognitive impairment and behavioral issues. During this incident, Resident #228 pulled Resident #48's arm, causing them to fall out of their wheelchair and sustain skin tears. The incident was witnessed by a former employee, RA/Receptionist #30, who attempted to intervene but was also involved in the altercation. In the second incident, Resident #228 was involved in a physical altercation with Resident #42, who had moderate cognitive impairment. Resident #228 slapped Resident #42 in the face twice after an argument ensued when Resident #42 denied Resident #228's request to enter their room. This incident was witnessed by ADON #2 and the CNA Coordinator, who intervened and separated the residents. Both incidents highlight the facility's failure to adequately supervise and manage residents with known behavioral issues, leading to physical abuse. The facility's policy on abuse prevention, investigation, and reporting was not effectively implemented, as evidenced by the repeated incidents involving Resident #228. Despite having care plans in place for residents with behavioral issues, the facility did not prevent these altercations, indicating a lack of adequate supervision and intervention strategies. The facility's inability to retrieve video footage of the incidents further complicates the investigation and highlights deficiencies in monitoring and documentation processes.
Failure to Protect Resident PHI
Penalty
Summary
The facility failed to protect the personal health information (PHI) of residents, specifically Resident #46 and Resident #55, as observed during a survey. For Resident #46, a whiteboard in the resident's room displayed PHI, including instructions for care and hospice information, which was visible from the hallway due to the open door. This was confirmed by multiple staff members, including a CNA Coordinator, an RN, and the Director of Nursing (DON), who acknowledged that the display of such information was a violation of HIPAA regulations. The resident's care plan did not indicate approval for the display of PHI in the room. Similarly, for Resident #55, a whiteboard in the resident's room contained PHI, including hospice staff names, which could be seen by visitors entering the room. The CNA Coordinator and Hospice CNA confirmed that PHI should not be visible, and the DON stated that if a resident wanted their information posted, it should be documented in their care plan. The Executive Director also expected no PHI to be visible unless desired by the resident or family. Both residents had cognitive impairments, and there was no indication that they or their representatives had approved the display of their PHI.
Failure to Conduct Criminal Background Check for CNA
Penalty
Summary
The facility failed to conduct a criminal background check for a Certified Nursing Assistant (CNA) prior to employment, which is a violation of their policy on abuse prevention, investigating, and reporting. The policy, last revised in July 2019, mandates that all potential employees and direct care volunteers undergo a criminal background check to screen for any history of abuse, neglect, or mistreatment of residents. The facility's employee list indicated that the CNA was hired in December 2023, but a review of the personnel records showed no evidence of a criminal background check being performed. Interviews with the Executive Director and the Director of Nursing revealed that the corporate office was responsible for completing these checks, but they failed to do so for this particular CNA.
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 17 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 Heber City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cascades At Orchard Park | 19.8 mi | ★★★★★ | 0 | 0 |
| Mission At Alpine Rehabilitation Center | 20.2 mi | ★★★★★ | 0 | 0 |
| Stonehenge Of Orem | 21.2 mi | ★★★★★ | 1 | 0 |
| Orem Rehabilitation And Nursing Center | 21.2 mi | ★★★★★ | 0 | 0 |
| Aspen Ridge Of Utah Valley | 21.8 mi | ★★★★★ | 4 | 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 October 2026) and official state health department websites.