Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Garfield County Nursing Home during CMS and state inspections, most recent first.
Surveyors found that kitchen staff did not consistently label or date food items in storage, left some foods open to air, and failed to wear required hairnets and beard coverings. Additionally, a sanitizer bucket was not at the required sanitation level, and an open drink was left on a food prep table. These actions did not meet professional standards for food service safety and hygiene.
Several residents were prescribed psychotropic medications, including antipsychotics, without documented attempts at gradual dose reduction (GDR) or clinical contraindications for not reducing the dose. Some residents received antipsychotic medications without an appropriate diagnosis, and staff interviews revealed uncertainty about the GDR process and lack of consistent documentation.
Three residents were incorrectly documented as taking antipsychotic medications on their MDS assessments, despite only being prescribed medications for depression, anxiety, or insomnia that are not classified as antipsychotics. This error was due to miscommunication between the MDS Coordinator, pharmacist, and DON regarding medication classification and documentation.
Three residents with either indwelling urinary catheters or open wounds did not have Enhanced Barrier Precautions (EBP) implemented, as evidenced by the absence of EBP signage and inconsistent use of gowns and gloves by staff. Interviews and record reviews showed that staff practices and understanding of EBP requirements varied, and the Infection Preventionist confirmed that EBP should have been in place for these residents.
A resident with dementia and incontinence was found with skin issues due to neglect in a LTC facility. An LPN suspected a CNA of not performing incontinence care, which was confirmed during rounds. The facility's investigation was inadequate, lacking thorough documentation and interviews. Despite policy, the CNA continued working, highlighting a deficiency in protecting residents during investigations.
Failure to Maintain Food Safety and Staff Hygiene Standards
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and staff hygiene practices within the facility's kitchen. During an initial tour, numerous food items in both the refrigerator and freezer were found to be undated and unlabeled, including bread, cheese, meats, soups, and desserts. Some items, such as roast beef and cheese, emitted a strong odor, and certain foods were left open to air. Additionally, an open energy drink was left on a food preparation table, and a sanitizer bucket was found to be below the required sanitation level. Staff interviews confirmed that food items should have been dated and labeled, and that open drinks should not be present in food prep areas. Further observations revealed that kitchen staff, including the Dietary Manager and cook, were not consistently wearing required hairnets or beard coverings while in the kitchen. The Dietary Manager and cook both acknowledged that staff should be wearing hairnets and beard nets, regardless of hair length, but were not in compliance at the time of observation. The Dietary Manager also admitted to removing outdated food from the refrigerator for personal use. These actions and inactions demonstrate a failure to adhere to professional standards for food service safety and hygiene.
Failure to Provide Gradual Dose Reductions and Appropriate Indications for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications were provided with gradual dose reductions (GDR) and behavioral interventions unless clinically contraindicated, as required. For four out of twelve sampled residents, there was no evidence of attempted GDRs for psychotropic medications, and clinical contraindications for not attempting GDRs were not documented. Specifically, residents with diagnoses such as depression, insomnia, anxiety, and dementia were prescribed medications including sertraline, zolpidem, diphenhydramine, quetiapine, mirtazapine, lorazepam, and fluoxetine without appropriate documentation of GDR attempts or clinical justifications for continued use at the current dosages. Additionally, antipsychotic medications such as quetiapine (Seroquel) were administered to residents without appropriate indications for use, such as for agitation or insomnia, rather than for approved psychiatric diagnoses. Interviews with facility staff, including the DON and Nurse Administrator, revealed a lack of clarity and involvement in the GDR process, with reliance on physician documentation and pharmacist reviews, but without consistent evidence of GDRs or clinical contraindications in the residents' records.
Inaccurate MDS Documentation of Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' medication status for three out of twelve sampled residents. Specifically, quarterly and annual Minimum Data Set (MDS) assessments incorrectly documented that these residents were taking antipsychotic medications, when in fact, their medication records showed they were only prescribed medications for depression, anxiety, or insomnia, none of which were classified as antipsychotics. The medications listed included nortriptyline, Effexor, Zoloft, Welbutrin, Celexa, clonazepam, and Remeron, all of which are not antipsychotic medications. Interviews with facility staff revealed confusion and miscommunication regarding the classification of these medications. The MDS Coordinator stated that the pharmacist conducted psychotropic medication reviews and had advised marking the residents as taking antipsychotics on the MDS assessments, despite the medications not fitting that category. The DON also expressed uncertainty about why the MDS assessments indicated antipsychotic use when the residents were not actually prescribed such medications. This resulted in inaccurate documentation of the residents' medication status on official assessments.
Failure to Implement Enhanced Barrier Precautions for Residents with Catheters and Wounds
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not implementing Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling urinary catheters. Specifically, three residents with either suprapubic catheters or open wounds did not have EBP signage in their rooms, and staff practices were inconsistent with EBP protocols. For example, one resident with a suprapubic catheter reported that staff only wore gloves when handling the catheter but never wore gowns, and there was no EBP signage present in the room. Another resident with a stage III coccyx ulceration and drainage also lacked EBP signage, despite ongoing wound care and offloading measures documented in the medical record. Interviews with staff, including the DON, MDS Coordinator, CNA, and Infection Preventionist, revealed inconsistent understanding and implementation of EBP. While some staff stated they would wear gowns when emptying catheters, others only used gloves for certain care activities. The Infection Preventionist acknowledged that EBP should be in place for residents with urinary catheters or open wounds and that signage should be posted, but this was not consistently done. These findings were based on direct observation, interviews, and record review.
Inadequate Investigation of Neglect Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident who was dependent on staff for toileting hygiene. The resident, who had multiple diagnoses including dementia and was always incontinent of urine, was found with redness and maceration in the perineal area due to prolonged exposure to urine. A Licensed Practical Nurse (LPN) suspected that a Certified Nurse Assistant (CNA) was not performing incontinence care as required, and this suspicion was confirmed when the LPN found the resident's brief soaked despite the CNA's claim of having changed it. The facility's investigation into the neglect allegation was inadequate. The investigation documentation was limited to forms submitted to the State Survey Agency, and there was no evidence of a thorough investigation. Interviews with the alleged perpetrator and other residents were not conducted, and the facility did not have documentation of interviews with key staff members involved in the incident. The facility's policy required protection of residents from further potential abuse during investigations, but the CNA continued to work at the facility after the incident. The facility's management team, including the Nurse Manager (NM), Clinical Operations Manager (COM), and Nursing Administrator (NADM), were involved in the investigation process. However, there was a lack of communication and documentation regarding the actions taken to address the neglect allegation. The NM was unaware that the CNA continued to work after the incident, and the COM confirmed that the CNA worked additional shifts. The facility's failure to suspend the CNA during the investigation and the lack of documentation of corrective actions contributed to the deficiency.
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 citations issued around you in the last 12 months — including the 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 Panguitch
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonehenge Of Cedar City | 26.7 mi | — | 4 | 0 |
| Cedar Health And Rehabilitation | 26.7 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Garfield County Nursing Home.
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 August 2026) and official state health department websites.