Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 South Davis Specialty Care during CMS and state inspections, most recent first.
Unsafe Food Handling During Tray Line Service: During lunch tray line service, a cook and a DA were observed handling food and dishes with dirty gloved hands after touching papers, doors, a food cart, an aluminum foil box, and a refrigerator door. The cook also repositioned food on a plate with contaminated gloves and wiped a bowl rim with a washcloth used on the counter before sending it to the tray line.
A resident with a feeding tube and diagnoses including cerebral palsy, respiratory failure, dysphagia, gastrostomy, and GERD was observed receiving enteral feeding while lying with the HOB at about 10 degrees, flat, and later at less than 30 degrees. RN, ADON, and DON stated the HOB should be at least 30 degrees during tube feeding, but the resident was not consistently positioned that way while the feeding pump was infusing.
Missing Lab Results in Resident Record: A resident with chronic respiratory failure with hypoxia had ordered BMP, ABG, and Vitamin D labs marked completed, but the corresponding results were not found in the chart. Staff described a fax-to-chart process involving nursing review, physician review, and medical records scanning, yet the lab reports were still missing from the resident's medical record.
A resident's urinalysis with culture and sensitivity was found in another resident's chart, and the issue involved 2 of 27 sampled residents. The MRL said records were sorted and verified before scanning, but a temporary remote worker had helped and his work was not checked. The DON stated that only the correct resident's lab results should be in that resident's medical record.
Unsafe Food Handling During Tray Line Service
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety during lunch tray line service. The cook was observed wearing gloves and then handling papers, picking up breadsticks with the same dirty gloved hand, and placing them on a resident's plate. The Dietary Aide was observed wearing gloves and touching a kitchen exit door, the food cart door, and an aluminum foil box before using a pinching method to handle a bowl and giving it to the cook to fill with soup for a resident's tray. Later during the same meal service, the cook was observed opening a cupboard with gloved hands to get a food scoop, then scooping chicken onto a plate and repositioning the chicken with dirty gloved hands. The cook also heated rice and tomato soup in the microwave and then wiped the rim of the rice bowl with a washcloth that had been used to wipe the counter before taking it to the tray line. The Dietary Aide was again observed touching the aluminum foil box, refrigerator door, and kitchen exit door, then picking up a bowl with the pinching method and touching the inside of the bowl with dirty gloves before filling it with food for a resident's lunch tray.
Improper Head-of-Bed Position During Tube Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding was provided appropriate treatment and services to prevent complications of tube feeding. Resident 8 was admitted with diagnoses including spastic quadriplegic cerebral palsy, acute and chronic respiratory failure, Familial Dysautonomia, epileptic spasms, dysphagia, gastrostomy, and gastro-esophageal reflux. The resident had a care plan for tube feeding related to inadequate oral intake due to disease and potential GI discomfort, with an intervention to elevate the head of the bed at least 30 to 45 degrees during feeding. The physician’s order directed enteral feeding at 72 mL/hr, and the treatment record indicated the head of bed should be elevated one-half hour before and after feedings. During observations, Resident 8 was seen receiving tube feeding while lying with the head of the bed at approximately 10 degrees, then later in the flat position, and on another occasion at slightly less than 30 degrees while the feeding pump was infusing at 72 mL/hr. RN 1 stated the head of the bed was about 25 degrees before it was raised and that it should be at least 30 degrees during and for 1 hour after tube feeding to decrease the risk of aspiration. The ADON and DON both stated that the head of the bed should be at 30 degrees during tube feeding, and the DON stated the resident should have had her head elevated to 30 degrees to prevent aspiration.
Missing Lab Results in Resident Record
Penalty
Summary
The facility failed to keep complete, dated laboratory records in the resident's clinical record for Resident 25, who was admitted with diagnoses including chronic respiratory failure with hypoxia. Review of the record showed physician orders for a BMP, an ABG, and Vitamin D that were marked completed, but the corresponding lab results could not be located in the resident's medical record. The missing results included the 4/17/25 BMP, the 4/17/25 ABG ordered for pulmonary clearance for surgery, and the 5/6/25 Vitamin D lab result. During interviews, staff described a process in which lab results were faxed to the facility, reviewed by nursing leadership and the physician, then placed in a medical records folder for scanning into the resident's chart. The Unit Secretary, Executive Assistance, Medical Records Lead, and DON each described this workflow and stated that the results should have been uploaded to the medical record within about a week. Despite this process, the three lab reports for Resident 25 were not found in the medical record, and the ES confirmed that the ABG was located in the respiratory therapy area while the BMP and Vitamin D results were still being sought.
Misfiled Lab Result in Another Resident's Medical Record
Penalty
Summary
The facility failed to ensure that each resident's medical record was accurately documented and maintained for 2 of 27 sampled residents when a resident's urinalysis with culture and sensitivity, dated 4/15/25, was found in another resident's medical record. During record review, the misplaced laboratory document was identified in one resident's chart even though it belonged to a different resident. The Medical Records Lead stated that medical records were collected from the nurses' stations each morning, sorted by name and date of service, and verified before scanning, but acknowledged that a temporary remote worker had assisted around April 2025 and that he should have checked that person's work but did not. The DON stated that only the correct resident's lab results should be in that resident's medical record and not in another resident's chart.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bountiful
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monument Healthcare North Park | 0.1 mi | — | 0 | 0 |
| Monument Healthcare Stonecreek | 0.9 mi | ★★★★★ | 3 | 0 |
| Monument Healthcare Bountiful | 1.9 mi | ★★★★★ | 3 | 1 |
| Midtown Manor | 8.5 mi | ★★★★★ | 0 | 0 |
| City Creek Post Acute | 8.6 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.