Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Southern Utah Veterans Home - Ivins during CMS and state inspections, most recent first.
Two residents with complex medical histories experienced uncontrolled pain that was not effectively addressed by staff, despite documented complaints and ineffective pain medication administration. Staff failed to notify providers or document follow-up actions as required, resulting in ongoing pain and incomplete incident reporting.
Multiple residents reported dissatisfaction with the quality, taste, and temperature of meals, including repetitive menu items, tough meats, cold food, and lack of appealing options. A test tray revealed undercooked rice, tough chicken, and food served below recommended temperatures. Ongoing complaints were documented in Dining Committee meetings, and interviews with dietary staff confirmed regular concerns about food quality.
A resident with a history of chronic pain and multiple comorbidities experienced severe, uncontrolled pain that was not relieved by prescribed medications. Despite documentation of ineffective pain relief, staff did not notify the physician as required by the care plan and facility protocol, and no additional interventions were documented until the hospice nurse was informed and the pain management plan was changed.
A resident with multiple chronic conditions had his aerosolized deodorant removed from his possession by a Resident Advocate, who stated that all pressurized items needed to be kept at the nurse's station. The resident, capable of self-care, was not given a choice in the matter and felt upset by the removal, while nursing staff confirmed there was no clinical reason for the restriction.
A resident was not provided with a Notice of Medicare Non-coverage (NOMNC) when Medicare Part A services ended, despite remaining in the facility. Staff interviews confirmed that the NOMNC was not issued or documented, even though the resident's payer changed and there was no change in out-of-pocket costs.
Two residents had inaccurate assessments: one was not coded for a PASRR level II despite having one for serious mental illness, and another was incorrectly documented as discharged to a hospital instead of home on hospice. Staff interviews and record reviews confirmed these discrepancies in the MDS documentation.
A resident with left-sided hemiplegia and a contracted wrist did not have a care plan addressing the use of a wrist splint, despite having the device and being intended to use it. There were no physician orders or care plan interventions for the splint, and staff confirmed its use was not consistently documented or planned.
A resident with Parkinson's disease and dysphagia, requiring assistance with oral hygiene, did not consistently receive oral care as documented in the care plan and posted instructions. CNA records showed oral hygiene was provided only sporadically, and dental records indicated significant oral health issues. Staff interviews confirmed that oral care should be performed and documented twice daily, but this was not consistently done, and no explanation was provided for the lapses.
A resident with left-sided hemiplegia and vascular dementia did not consistently receive a prescribed hand/wrist splint, as CNAs were unaware of the device and there were no physician orders or care plan interventions documented. The splint, intended to maintain range of motion, was not applied for an extended period, and its use was not properly coordinated or recorded by nursing staff.
A resident with hemiplegia and multiple medical conditions, who was care planned for two-person assist with bed mobility and incontinence care, experienced a fall when only one CNA provided care. The CNA was unaware of the two-person assist requirement documented in the Kardex and care plan. Staff interviews confirmed the resident's dependency on two-person assistance, and the DON acknowledged that the care plan instructions were not followed, resulting in the resident's environment not being kept free from accident hazards.
A resident with multiple psychiatric and medical conditions had PRN Lorazepam orders that exceeded 14 days without proper documentation of a stop date or rationale for extended use. Despite the pharmacist's recommendation to address this, the required documentation was not found in the medical record, resulting in a deficiency related to medication management.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents who required such services, as evidenced by multiple instances of unaddressed or ineffectively managed pain. For one resident with a history of palliative care, dementia, traumatic brain injury, and chronic pain conditions, there were documented complaints of severe pain in the right shoulder and neck. Despite administration of prescribed pain medications such as Oxycodone and Acetaminophen, the pain was reported as ineffective on several occasions. There was no documentation that the provider was notified of the ineffective pain relief, nor evidence of follow-up interventions or reassessment as required by the resident's care plan and facility policy. Interviews with nursing staff and the DON confirmed that provider notification and documentation were expected but not completed in these instances. Another resident with hemiplegia, aphasia, and a history of cerebral infarction experienced right shoulder pain following a dislocation, which was suspected to have occurred during a transfer. The resident received pain medications and non-pharmacological interventions, but these were documented as ineffective on more than one occasion. There was no evidence that additional pain management strategies were implemented or that the provider was promptly notified of the ongoing uncontrolled pain. Nursing notes indicated that the resident continued to experience pain, and staff interviews revealed uncertainty about the origin of the injury and incomplete incident reporting. The DON acknowledged that an abuse investigation was initiated but not completed, and there was a lack of detailed documentation regarding staff interviews and the cause of the injury. Both cases demonstrate a failure to follow professional standards of practice and the residents' person-centered care plans regarding pain management. The facility did not ensure timely notification of providers when pain interventions were ineffective, nor did it consistently document follow-up actions or reassessments. These deficiencies resulted in residents experiencing uncontrolled pain without appropriate escalation or modification of their pain management plans.
Deficiency in Food Quality, Palatability, and Temperature
Penalty
Summary
The facility failed to provide food that was consistently palatable, attractive, and served at a safe and appetizing temperature for multiple residents. Nine residents reported various concerns, including repetitive and unappealing menu options, such as hot dogs being served multiple times a week, tough and hard-to-chew meats, and food that was cold or not visually appealing. One resident, who was previously vegan, noted a lack of raw fruits and vegetables and described the vegetables as overcooked, while another resident reported not receiving requested food items. Several residents described the food as bland, unappetizing, or not tasting good, with one resident stating he purchased his own food due to dissatisfaction with the facility's meals. A test tray evaluation revealed that the food served was not attractive or palatable, with undercooked rice, tough chicken, and dull-colored beets. The temperature of the food was also below recommended standards, with the chicken and rice at 112.7°F and the beets at 108.3°F. The combination of gravies and sauces on the chicken and rice was described as having conflicting flavors, further detracting from the meal's palatability. The posted menu did not match the meal served, and the dessert was store-bought pie, which was not prepared in-house. Dining Committee meeting minutes over several months documented ongoing complaints from residents about food quality, including issues with food temperature, texture, doneness, and flavor. Specific complaints included cold food, undercooked or overcooked vegetables and meats, bland taste, and inconsistencies in meal preparation. Interviews with the Registered Dietitian and Dietary Manager confirmed that food quality concerns were raised regularly, though they believed the same residents typically voiced these issues. The Administrator was unaware of the extent of food concerns, despite mechanisms in place for residents to file grievances or use a QR code to report complaints.
Failure to Notify Physician of Ineffective Pain Management
Penalty
Summary
A deficiency was identified when the facility failed to immediately consult with a resident's physician following significant complaints of uncontrolled pain. The resident, who had a complex medical history including palliative care, dementia, traumatic brain injury, and chronic pain conditions, reported severe pain in the right shoulder and neck, rating it as 8 out of 10. Despite having orders for Oxycodone and Acetaminophen as needed for pain, documentation showed that pain medications were administered on multiple occasions with noted ineffectiveness, yet there was no evidence that the physician was notified of the ineffective pain management as required by the resident's care plan. Interviews with nursing staff and the Director of Nursing confirmed that the facility's protocol required physician notification when pain interventions were unsuccessful, and that such notifications should be documented in the medical record. However, review of the records revealed no documentation of provider notification or additional pain management interventions following reports of ineffective pain relief. The hospice nurse was only notified of the resident's uncontrolled pain after repeated ineffective pain management, leading to a change in the pain management plan.
Resident's Right to Personal Choice Not Supported Due to Removal of Deodorant
Penalty
Summary
A deficiency was identified when a resident's right to self-determination and choice was not supported by the facility. The resident, who had a history of type II diabetes mellitus, chronic obstructive pulmonary disease, emphysema, cervicalgia, hypertension, low back pain, and pulmonary hypertension, reported that his aerosolized can of deodorant was removed from his possession. The resident stated that the deodorant was taken by the Resident Advocate (RA) due to the presence of state surveyors, despite no prior concerns about the item. The resident expressed feeling upset about the removal and indicated that he felt unable to refuse the RA's request to search his room. Further investigation revealed that the resident was capable of self-care and did not require assistance with applying deodorant. A registered nurse confirmed there was no reason for the resident not to have the deodorant in his room and was unaware of its removal. The RA acknowledged removing the deodorant, stating he was instructed that all pressurized items needed to be kept at the nurse's station. The deodorant was not found in the medication cart during inspection.
Failure to Issue Notice of Medicare Non-coverage Upon Termination of Part A Services
Penalty
Summary
The facility failed to inform a resident of the termination of Medicare Part A coverage by not issuing a Notice of Medicare Non-coverage (NOMNC) as required. Specifically, one resident who was discharged from Medicare Part A services but remained in the facility did not have a NOMNC in their medical record. Interviews with staff revealed that the Social Services Department was responsible for issuing NOMNCs, and Medical Records was responsible for uploading signed copies into the resident's record. However, no NOMNC was found for this resident. Staff acknowledged that the NOMNC should have been provided, even though the resident's payer changed and there was no impact on out-of-pocket expenses.
Inaccurate Resident Assessments Documented
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the status of two residents. For one resident with diagnoses including palliative care, Parkinson's disease, and dysphagia, the Minimum Data Set (MDS) did not indicate the presence of a PASRR level II, despite documentation in the medical record and confirmation by staff that the resident had a PASRR level II related to serious mental illness, post-traumatic stress disorder, and major depressive disorder. For another resident with diagnoses including dementia, pacemaker, post-traumatic stress disorder, and chronic kidney disease, the discharge MDS incorrectly coded the resident as being discharged to a short-term general hospital, while progress notes and staff interviews confirmed the resident was actually discharged home on hospice. These inaccuracies were identified through interviews with facility staff and review of medical records, demonstrating that the assessments did not accurately reflect the residents' actual conditions or discharge locations.
Failure to Develop and Implement Comprehensive Care Plan for Wrist Splint
Penalty
Summary
A deficiency was identified when a resident with a history of palliative care, hemiplegia and hemiparesis of the left side following a cerebral infarction, and vascular dementia did not have a comprehensive, person-centered care plan addressing all of their needs. Specifically, the resident had a contracted left wrist and was provided with a wrist splint, but there was no documentation of physician orders for the splint, nor was the use of the splint included in the resident's care plan. The resident reported limited movement in the left hand and arm, and stated that he was supposed to wear the brace in the afternoon and evening, but had not worn it for approximately two weeks because CNAs had difficulty applying it. The resident clarified that he did not refuse the brace. Record review confirmed the absence of orders for the wrist splint and no care plan interventions related to the splint. Interviews with nursing staff and the DON confirmed that the brace was provided by the hospice nurse manager and was occasionally used to maintain comfort, but its use was not formally documented or care planned. The DON acknowledged that the care plan should have included all care being provided, including the wrist splint.
Failure to Provide Consistent Oral Hygiene Assistance
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate oral hygiene care to a resident with significant medical needs, including Parkinson's disease, dysphagia, and a need for palliative care. The resident required supervision or assistance with oral hygiene, as documented in the care plan and Minimum Data Set (MDS). Despite clear instructions posted on the resident's door and care plan interventions specifying the need for staff assistance with oral care, documentation and interviews revealed that oral hygiene was not consistently provided as required. CNA documentation showed that oral care was only performed sporadically over a one-month period, rather than the expected twice daily frequency. Interviews with staff confirmed that oral hygiene should be performed and documented twice daily, but this was not consistently done, and no clear reason was provided for the lapses. Further evidence of inadequate oral care was found in dental records, which noted heavy debris, gum inflammation, and tooth decay, necessitating dental intervention. The resident's family member also reported that oral hygiene was not performed regularly, resulting in dental issues. Staff interviews indicated that oral hygiene was a CNA responsibility and should be documented, with refusals reported to nursing staff. However, there was no documentation of refusals or consistent provision of care, and leadership was unable to explain the lack of compliance with the care plan and posted instructions.
Failure to Ensure Proper Orders and Consistent Application of Hand/Wrist Splint
Penalty
Summary
A deficiency was identified when a resident with limited movement in the left hand and arm, following a cerebral infarction and with diagnoses including hemiplegia, hemiparesis, and vascular dementia, did not receive consistent application of a prescribed hand/wrist splint. The resident reported that the brace was supposed to be worn in the afternoon and evening but had not been applied for approximately two weeks, not due to refusal but because CNAs had difficulty putting it on. Observation confirmed the resident's left wrist was contracted, and interviews with CNAs revealed they were unaware of any wrist brace for the resident, only acknowledging a brace for the ankle/foot. Review of the resident's medical record showed no physician orders for the hand/wrist splint, and the care plan lacked any focus or interventions related to the splint. The RN confirmed the absence of orders and stated the brace was occasionally applied for comfort, having been provided by the hospice nurse manager. The DON acknowledged that orders should have been in place for the splint and that the care plan should have included this intervention, confirming that the device had been used without proper documentation or physician authorization.
Failure to Provide Required Two-Person Assist Leads to Resident Fall
Penalty
Summary
A deficiency occurred when a resident, who was care planned as requiring a two-person assist for bed mobility and incontinence care, sustained a fall during incontinence care that was being provided by only one CNA. The resident had significant medical conditions, including hemiplegia and hemiparesis following a cerebral infarction, vascular dementia, and a history of right shoulder injuries and a left humerus fracture. Despite the care plan and Kardex indicating the need for two-person assistance, the CNA provided care alone, stating she was unaware of the requirement and had previously performed the task solo. During the incident, the resident attempted to assist with repositioning, resulting in a fall from the bed and subsequent injuries, including pain and skin tears. Interviews with multiple CNAs and nursing staff confirmed that the resident was dependent on two-person assistance for most ADLs, including bed mobility and toileting, due to left-sided paralysis and insufficient upper body strength. The CNA involved in the incident reported that she was not aware of the two-person assist requirement documented in the Kardex and care plan. Other staff members corroborated that the resident had always required substantial assistance and that this information was available in the Kardex and communicated during shift reports. Documentation and interviews revealed that the care plan had consistently indicated the need for two-person assistance since its initiation. However, there was a lack of adherence to this requirement at the time of the fall, as only one CNA was present during the provision of care. The Director of Nursing acknowledged that staff should have followed the care plan instructions regarding the number of staff required for assistance, and that the resident's environment was not maintained as free from accident hazards as possible due to this lapse.
Failure to Act on Pharmacist's Recommendations for PRN Lorazepam Orders
Penalty
Summary
The facility failed to ensure that irregularities identified by the pharmacist during the monthly drug regimen review were acted upon by the attending physician for one resident. Specifically, the pharmacist noted that the resident had a PRN order for Lorazepam that exceeded 14 days without a documented stop date or a rationale for extending the use or duration of treatment. Despite the pharmacist's recommendation to add a stop date and, if necessary, document the indication, intended duration, and rationale for continued use, there was no evidence in the resident's medical record that these requirements were met. The resident involved had multiple diagnoses, including palliative care, vascular dementia, cognitive communication deficit, anxiety disorder, post-traumatic stress disorder, and major depressive disorder. Multiple Lorazepam orders were initiated and discontinued over several months, with at least one order lacking the required documentation for extended PRN use. Although a handwritten note on the pharmacy report indicated a stop date was in place, the medical record did not contain the necessary documentation to support the extended use of Lorazepam as required by CMS guidelines.
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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 Ivins
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Seasons Healthcare And Rehabilitation | 6.4 mi | — | 0 | 0 |
| St. George Rehabilitation | 8 mi | — | 0 | 0 |
| Bella Terra St George | 8 mi | — | 4 | 0 |
| Red Cliffs Health And Rehab | 8.7 mi | — | 0 | 0 |
| Coral Desert Rehabilitation And Care | 8.8 mi | — | 0 | 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.