Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Uintah Health Care Special Service District during CMS and state inspections, most recent first.
Two residents expressed suicidal ideation, with one ultimately committing suicide, after the facility failed to provide necessary behavioral health care, interventions, or monitoring. Despite repeated statements of depression and suicidal thoughts, staff did not consistently notify the physician or implement appropriate suicide prevention measures, resulting in a deficiency at the Immediate Jeopardy level.
The facility failed to ensure psychotropic medications were free from unnecessary use because monitoring was not documented for behaviors, ASE, and non-pharmacological interventions for three residents. One resident receiving trazodone for insomnia had no documented ASE or non-pharmacological monitoring, another resident receiving buspirone and sertraline had no documented monitoring despite behaviors including refusal of care, aggression, and delusions, and a third resident receiving venlafaxine and clonazepam had no documented monitoring for side effects or behaviors. The DON acknowledged that monitoring for anti-depressants, anti-anxiety medications, and hypnotics was not documented.
Failure to notify the Ombudsman of a resident’s discharge to home. A resident with fractures of the L femur and R humerus, and a fall history, was discharged after the MD documented the resident wanted to go home and ordered discharge, PT, and medication release. The MRC and DON stated they only notified the Ombudsman for hospital transfers, not community discharges.
Missing laboratory results were found for a resident with amnesia, bipolar disorder, OCD, and drug-induced movement disorder. A physician ordered CBC, CMP, TSH, and lipid panel testing, but the results were not located in the EMR. RN and DON stated lab results are typically faxed, entered as a progress note, and filed in the resident's chart, but the ordered results had been sent to the physician's office instead of the facility.
A resident with a chronic, draining abdominal abscess did not have EBP implemented. Surveyors observed no EBP signage in the room, and staff interviews showed a CNA believed signs were only for isolation, an LPN had not heard of EBP and used only gloves for dressing changes, and the DON confirmed the resident’s open, draining abdominal abscess required EBP but the facility did not post signage.
Failure to Provide Behavioral Health Services Following Suicidal Ideation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to two residents who expressed suicidal ideation, resulting in one resident successfully committing suicide. One resident, with diagnoses including Alzheimer's disease, major depressive disorder, anxiety disorder, and insomnia, repeatedly expressed feelings of depression, hopelessness, and suicidal thoughts to staff over several months. Documentation shows that this resident made multiple statements about wanting to die, feeling suicidal, and having no interest in life, yet there was no evidence that appropriate interventions or monitoring were implemented in response to these statements. In several instances, the resident's expressions of suicidal ideation were not communicated to the physician, and there was a lack of documented follow-up or increased supervision. The resident's medical record revealed a history of severe depression, agitation, and behavioral symptoms, with mood assessments indicating a high severity of depression. Despite these ongoing concerns, the only documented assessment by a Licensed Clinical Social Worker or mental health provider was conducted early in the resident's stay, and there was no evidence of ongoing behavioral health interventions or monitoring tailored to the resident's escalating risk. The resident continued to display signs of isolation, agitation, and suicidal ideation, including direct statements about wanting to die and refusing to participate in activities or meals. Ultimately, the resident was found deceased in his room after a successful suicide attempt, with no documentation of suicide prevention measures having been implemented prior to the event. A second resident also made statements about wanting to hang himself, but there was no documentation that behavioral health services, interventions, or monitoring were provided in response. The facility's failure to act on clear indications of suicidal ideation and to implement necessary behavioral health care and services for both residents constituted a deficiency at the Immediate Jeopardy level, as it did not ensure the residents' highest practicable physical, mental, and psychosocial well-being in accordance with their comprehensive assessments and care plans.
Unnecessary Psychotropic Medication Use Without Required Monitoring
Penalty
Summary
The facility did not ensure that each resident’s drug regimen was free from unnecessary drugs because psychotropic medications were prescribed without documented monitoring for episodes of behavior, adverse side effects, and non-pharmacological interventions for 3 of 22 sampled residents. The deficiency involved residents receiving trazodone, buspirone, sertraline, clonazepam, and venlafaxine, with survey review finding no documentation for the required monitoring elements for these medications. One resident with neurocognitive disorder with Lewy Bodies, schizophrenia, delusional disorder, and insomnia had trazodone ordered for insomnia. Review of the September 2025 MAR and TAR found no documentation of adverse side effect monitoring or non-pharmacological interventions for the trazodone. A CNA stated the resident had not been sleeping well and did not sleep great most of the time, but no non-pharmacological interventions were reported. The DON stated that hours of sleep were recorded for hypnotics in the TAR, but adverse side effects and non-pharmacological interventions were not monitored for hypnotics. A second resident with anxiety disorder and dementia had buspirone, sertraline, and Seroquel ordered for anxiety, striking out, resisting care, delusions, and unspecified dementia. No documentation was found for monitoring episodes of behavior, adverse side effects, or non-pharmacological interventions for buspirone and sertraline. Staff interviews described refusal of cares, exit seeking, verbal and physical aggression, and delusional/paranoid statements, and the DON stated that monitoring for anti-depressants, anti-anxiety medications, and hypnotics was not documented and that this monitoring was missed. A third resident with Alzheimer’s disease, Down syndrome, major depressive disorder, anxiety disorder, and dementia had venlafaxine and clonazepam ordered, but no documentation was found for adverse side effect monitoring, behavior monitoring, or non-pharmacological interventions for those medications. An LPN stated the resident was monitored for delusions and paranoid statements with antipsychotic use, but there was no binder or record for behaviors or side effects from venlafaxine and clonazepam.
Failure to Notify Ombudsman of Community Discharge
Penalty
Summary
The facility failed to send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 22 sampled residents. Resident 38 was admitted with diagnoses including an unspecified fracture of the left femur, an unspecified fracture of the right humerus, and an unspecified fall. The resident’s record showed that on 8/11/25, medication, follow-up appointments, and home health PT were discussed with the resident and husband, and the resident was assisted to a private motor vehicle via wheelchair after expressing appreciation for the care. The record also showed that on 8/12/25, the physician documented that the resident requested to go home and entered orders allowing discharge to home, along with PT orders and release of medications to the resident. During interview, the Medical Record Coordinator stated that the Ombudsman was notified only for unexpected transfers and discharges to the hospital and that she did not notify the Ombudsman for Resident 38 because the discharge was to home. The DON stated she was only aware of having to notify the Ombudsman for residents discharged to a hospital.
Missing Laboratory Results in Resident Record
Penalty
Summary
Complete, dated laboratory records were not kept in the resident's clinical record for 1 of 22 sampled residents. Resident 21 was admitted and later readmitted with diagnoses including other amnesia, borderline intellectual functioning, bipolar disorder, obsessive-compulsive disorder, and drug induced movement disorder. On 8/28/25, a physician saw the resident and ordered a CBC, CMP, TSH, and lipid panel to be drawn on 9/2/25, and the physician's order was entered the same day. Review of the resident's medical record showed no CBC, CMP, TSH, or lipid panel results located in the electronic medical record. RN 2 stated that laboratory results are faxed from the local hospital, the nurse informs the physician, enters the results as a progress note in the EMR, and files the paper fax copy in the resident's hard chart. The DON stated that facility staff draw the ordered labs and take them to the local hospital for processing, the hospital faxes the results, and the nurse places the faxed results in the resident's hard medical chart; the DON also stated the MDS coordinator tracks lab requests to ensure completion and filing in both the electronic and hard medical record. The DON later stated the floor nurse had called the physician's main office to obtain the CBC, CMP, TSH, and lipid panel results, and that the laboratory sent the results to the physician's office rather than the facility because the orders came from the physician's main office.
EBP Not Implemented for Resident With Chronic Draining Abdominal Abscess
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program for a resident with a chronic abdominal abscess wound. Resident 5 was admitted with diagnoses including cutaneous abscess of the abdominal wall, weakness, and unspecified severe protein-calorie malnutrition. The resident’s record showed ongoing abdominal wound care, including orders to monitor the chronic abdominal opening, clean it with normal saline, cover it with ABD and tegaderm bandages every shift, and apply Cavilon Advanced Skin protectant to the area surrounding the abdominal abscess every Tuesday. Surveyors observed the resident’s room on 9/23/25 and found no signage indicating that enhanced barrier precautions were required. The resident’s progress notes documented a chronic abdominal abscess with drainage, odor, leakage, and repeated dressing or appliance changes related to the wound. During interviews, a CNA stated there were no signs posted for residents requiring EBP and that signs were used only for isolation. An LPN stated she had not heard of EBP and said she only wore gloves when changing the resident’s abdominal dressings. The DON stated staff should wear gloves and gowns for residents requiring EBP, that the facility did not post EBP signage, and that the resident’s chronic open and draining abdominal abscess required EBP.
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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 Vernal
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Uintah Basin Rehabilitation And Senior Villa | 26.6 mi | ★★★★★ | 1 | 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 August 2026) and official state health department websites.