2200 East 3300 South, Salt Lake City, UT 84109 · Salt Lake County · (801) 486-2096
100 certified beds, about 60 residents a day · For profit - Corporation · Medicare and Medicaid since 1977
CMS Care Compare ratings, data as of September 1, 2026 · CCN 465006 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on May 9, 2024, inspectors cited 7 health deficiencies (the Utah average is 8.8, the national average 9.2).
Of 66 health citations since July 2021, 5 were rated as actual harm or immediate jeopardy to residents (3 immediate jeopardy).
CMS lists 5 fines totaling $149,703 in the last three years; the largest was $87,712, and the latest is dated October 24, 2025.
Nurses and nurse aides worked 3.63 hours per resident per day, against 4.09 across Utah and 3.86 nationally. Registered nurses accounted for 0.89 of those hours.
58.6% of nursing staff left within the year CMS measured (Utah average 50.7%).
CMS links it to Cascades Healthcare, an affiliated group of 19 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 66 health citations on file.
Inspectors wroteBased on observation, interview, and record review, it was determined that, for 3 out of 23 sampled residents, the facility failed to ensure each resident had the right to choose activities, schedules, health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part; and to make choices about aspects of his or her life in the facility that were significant to the resident. Specifically, three residents were restricted to supervised smoking and designated smoking times when they were assessed to have the functional capacity to smoke independently and one resident's request to be taken off of an antipsychotic medication was not completed as ordered. Resident identifiers: 6, 32, and 66. 1. [...]
Inspectors wroteBased on interview and record review it was determined, for 3 out of 23 sampled residents, that the facility did not maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized. Specifically, a physician visit note was not documented in the medical record, a resident's medication administration record was not accurately completed, and a physician's note was entered late in the resident's medical record. Resident identifiers: 6, 10, and 41 1. Resident 6 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, recurrent, severe with psychotic symptoms; unspecified psychosis; delusional disorders; anxiety disorder; and post-traumatic stress disorder. Resident 6's medical record was reviewed 6/22/26 through 6/29/26. [...]
Inspectors wroteBased on record review and interview, it was determined that the facility failed to maintain documentation related to staff COVID-19 vaccination that included that staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine; offered the COVID-19 vaccine or information on obtaining COVID-19 vaccine; and the COVID-19 vaccine status of staff and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN). Specifically, 4 staff members had no documentation that they were offered or provided Covid-19 immunizations. Staff identifiers: 1, 2, 3, and 4. On 6/29/26 at 9:00 AM, the employee records were reviewed for Staff 1, 2, 3, and 4. There was no documentation that indicated immunizations had been offered or administered to the staff members. [...]
Inspectors wroteBased on interview and record review, it was determined that, for 1 out of 23 sampled residents, the facility failed to ensure each resident was informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred. Specifically, one resident was on Olanzapine and there was no documentation that she was informed of the risks and benefits or treatment or treatment alternatives or options. Resident identifier: 6Resident 6 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, recurrent, severe with psychotic symptoms; unspecified psychosis; delusional disorders; anxiety disorder; and post-traumatic stress disorder. Resident 6's medical record was reviewed 6/22/26 through 6/29/26. [...]
Inspectors wroteBased on interview and record review, it was determined that for 1 of 23 sampled residents, that the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, one resident was not tapered off of Olanzapine as ordered and requested by the resident. Resident identifier: 6. On 6/22/26 at 10:14 AM, an interview was conducted with resident 6 who stated she felt the Nurse Practitioner (NP) was not listening to her because it had been weeks since she asked to be taken off Olanzapine, but all that had happened was that the dose was lowered. Resident 6 stated she also spoke to the Medical Doctor because she was not taken off of the medication and still nothing changed. [...]
Inspectors wroteBased on observation, interview, and record review, it was determined that for 1 of 23 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible. Specifically, a resident was found to have a nicotine vape in his possession despite being assessed as requiring supervision when smoking. Resident identifier: 3. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included osteomyelitis of vertebra lumbar region, bacteremia, methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere, type 1 diabetes mellitus without complications, and other psychoactive substance abuse with psychoactive substance-induced mood disorder. Resident 3's medical record was reviewed from 6/22/26 through 6/29/26. [...]
Inspectors wroteBased on interview and record review, the facility did not ensure that 1 of 23 sample residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter. Resident identifier: 4. Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy, osteomyelitis of vertebra, streptococcus group A, pressure ulcer of the sacral region and right buttock, myocardial infarction and chronic respiratory failure. Resident 4's medical record was reviewed on 6/29/26. Resident 4's progress notes were reviewed. The progress notes indicated that resident 4 had been seen by the facility physician on the following dates after the latest admission: 3/23/265/26/26Documentation for the physician visit from April 2026 was not observed in the medical record. [...]
Inspectors wroteBased on record review and interview, it was determined that for 1 of 23 sampled residents, the facility failed to ensure that each resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. Specifically, one resident opted to receive the pneumococcal immunization but it was not provided. Resident identifier: 10. Resident 10 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and severe dementia with psychotic disturbance. Resident 10's medical record was reviewed 6/22/26 through 6/29/26. An Immunization Consent dated 3/4/26 indicated resident 10 consented to, Pneumococcal Vaccine to be administered on 3/10/26. It should be noted that there was no documentation in the medical record that resident 10 received a Pneumococcal Vaccine. [...]
Inspectors wroteBased on observation, interview, and record review, it was determined for 1 out of 10 sampled residents, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident was dropped from a hoyer lift and died; the facility used a transfer sheet and not an approved Hoyer sling while transferring the resident. Resident identifier: 3. NOTICE:Notice of Immediate Jeopardy (IJ) was given verbally to the Administrator on [DATE] at 11:00 AM. The Administrator was asked to develop an immediate plan to ensure resident safety related to Hoyer lifts and Hoyer slings. PLAN:On [DATE] at 6:26 PM, the facility Administrator provided the following abatement plan for the removal of the IJ effective at [DATE] at 10:00 PM. [...]
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Specifically, Certified Nursing Assistants (CNA)'s had not been educated on the correct way to use a Hoyer lift, approved Hoyer slings, and how to identify a transfer sheet. Additionally, a resident was dropped from the Hoyer lift while on a transfer sheet and died. Resident identifier: 3. NOTICE:Notice of Immediate Jeopardy (IJ) was given verbally to the Administrator on [DATE] at 11:00 AM. [...]
Inspectors wroteBased on interview and record review, it was determined for 1 of 38 sampled residents, that the facility did not notify a representative of the Office of the State Long-Term Care Ombudsman of the transfer or discharge and the reasons for the move in writing. Specifically, when a resident was discharged to the hospital, the Ombudsman was not notified. Resident identifier: 21.
Inspectors wroteBased on interview and record review, the facility did not ensure that 4 of 38 sample residents were provided adequate supervision and assistance devices to prevent accidents. Specifically, residents had a wanderguard placed without a physician order or assessment. In addition, residents were able to elope from the facility multiple times without additional interventions put into place. Resident identifiers: 120, 121, 125, and 127.
Inspectors wroteBased on observation and interview it was determined, the facility did not establish and 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. Specifically, for 1 out of 38 sampled residents, a staff member was observed to touch a resident medications with bare hands with each medication administration. Also medications were dropped on and in the medication cart and then administered to the residents
Inspectors wroteBased on interviews and record review, the facility did not develop and implement a baseline care plan for 2 of 38 sample residents that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care, and be developed within 48 hours of the resident's admission. Specifically, a care plan was initiated 7 days after admission for two residents. Resident identifiers: 55 and 167.
Inspectors wroteBased on interview and record review, the facility did not ensure that care plans for 2 of 38 sample residents were developed within 7 days after the completion of the comprehensive assessment, or revised by the interdisciplinary team after each assessment. Resident identifiers: 121 and 127.
Inspectors wroteBased on interview and record review it was determined, for 1 of 38 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicated that the dose should be reduced or discontinued. Specifically, a resident's blood pressure (B/P) medication was administered outside of physicians ordered parameters. Resident identifier: 4.
Inspectors wroteBased on observation and interview, the facility did not label all drugs and biologicals used in the facility in accordance with currently accepted professional principles and included appropriate accessory instructions and the expiration date when applicable. Specifically, narcotics were repackaged into the narcotic medication cards.
Inspectors wroteHARM 9. Resident 47 was admitted to the facility on [DATE] with diagnoses that included but not limited to spina bifida, type two diabetes mellitus with hyperglycemia, muscle weakness, bladder disorder, anxiety disorder, chronic pain, essential hypertension and a colostomy. On 2/6/23 at 12:31 PM, an interview was conducted with resident 47. Resident 47 stated he fell from his wheel chair onto his buttocks when he was transported to this doctor's appointment. Resident 47 stated he fell in the van right before his doctor's appointment. Resident 47 stated it happened because his seat belt was not secured properly. Resident 47 stated he had a new driver that day and they were aware on how to secure his wheelchair in the van and tighten his seat belt. Resident 47 stated that on his way to the appointment, he kept slipping out of his wheelchair every time the driver had to brake. [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies; and regularly review and analyze data, including data collected under the QAPI (Quality Assurance and Performance Improvement) program, and act on available data to make improvements. Specifically, deficient practices identified during the survey included repeat deficiencies in the areas of prevention of accident hazards, physician notification in changes of condition, quality of care related to hospice services, resident's free from unnecessary medications, and maintaining laboratory reports in the resident records. Resident identifiers: 4, 11, 17, 18, 20, 31, 32, 47, 56, 68, 77, 134, 181, and 231.
Inspectors wroteBased on record review and interview, it was determined, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, for 1 out of 41 sampled residents, a resident who attempted suicide in the facility was not receiving behavioral health services when there were multiple recommendations for behavioral health services prior to the incident. Resident identifier: 134.
Inspectors wroteBased on observation and interview, it was determined, the facility did not provide a clean, comfortable homelike environment. Specifically, for 5 out of 41 sampled residents, resident rooms were dirty, a sit to stand lift was dirty, resident wheelchairs were dirty, and furniture was broken. Resident identifiers: 10, 15, 36, 54, and 72.
Inspectors wroteBased on interview and record review it was determined, for 4 out of 41 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials. Specifically, an accident in which a resident sustained second degree burns when his oxygen ignited while smoking a cigarette unsupervised was not reported to the State Survey Agency (SSA) or Adult Protective Services (APS). Two allegations of resident abuse were not reported to the SSA or APS. [...]
Inspectors wrote3. Resident 3 was admitted to the facility on [DATE] with diagnoses that included but not limited to schizoaffective disorder, Parkinson's disease, major depressive disorder, insomnia, cognitive communication deficit, and type 2 diabetes mellitus. Resident 3's medical records were reviewed on 2/7/23 Resident 3's progress notes revealed the following: a. Nursing note dated 12/6/22 documented as followed: rec'd [received] call from 911 dispatch stating resident called saying that she had been strangled. upon entering room, res [resident] was noted to be laying on bed, talking on the phone w/ [with] 911 dispatch. res handed phone to this nurse, confirmed that emergency response not needed. asked resident what happened, res then responded stating 'I only have 1/4 of a brain', res redirected to statement to dispatch that 'someone strangled her'. [...]
Inspectors wroteBased on interview and record review, it was determined, the Minimum Data Set (MDS) assessments did not accurately reflect the resident's status. Specifically, for 5 out of 41 sampled residents, residents that had Preadmission Screening and Resident Review (PASRR) level II's completed did not have the PASRR indicated on the MDS assessments. Resident identifiers: 11, 10, 16, 20, and 36.
Inspectors wroteBased on observation, interview, and record review it was determined, for 3 out of 41 sampled residents, that the facility did not develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care to meet professional standards of quality care. Specifically, residents did not have a baseline care plan developed within 48 hours of admission, and the baseline care plan did not include the minimum healthcare information necessary to properly care for the residents. Resident identifiers: 32, 64, and 78.
Inspectors wroteBased on observation, interview and record review it was determined, for 9 of 41 sampled residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, residents care plans did not address care areas such as pain, falls, smoking, and activities of daily living (ADL) assistance. Resident identifiers: 3, 4, 6, 17, 18, 24, 54, 78, and 134. Findings Included: 1. Resident 3 was admitted to the facility on [DATE] with diagnoses that included but not limited to schizoaffective disorder, Parkinson's disease, major depressive disorder (MDD), insomnia, cognitive communication deficit, and type 2 diabetes mellitus (DMII). Resident 3's medical records were reviewed on 2/7/23 An Annual Minimum Data Set (MDS) dated [DATE] documented Resident 3 required a one person limited assist while ambulating throughout the facility. [...]
Inspectors wroteBased on interview and record review it was determined, for 4 of 41 residents sampled, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicated that the dose should be reduced or discontinued. Specifically, residents' medications were not administered or held per the physician ordered parameters. Resident identifier: 11, 31, 32, and 47.
Inspectors wroteBased on interview and record review, it was determined, the facility did not file in the resident's clinical record laboratory (lab) reports that were dated and contained the name and address of the testing laboratory. Specifically, for 3 out of 41 sampled residents, a resident that had a UA completed did not have the sensitivity report at the facility or filed in their medical record. In addition, a resident that had a Troponin and Creatine Kinase (CK) ordered for chest pain did not have the report at the facility or filed in their medical record, and a resident that had an influenza nasal swab ordered did not have the report at the facility or filed in their medical record. Resident identifiers: 11, 20, and 68.
Inspectors wroteBased on observation, interview, and record review, it was determined, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized. Specifically, for 3 out of 41 sampled residents, a resident with an arteriovenous (AV) fistula in his left arm had multiple blood pressure readings that were inaccurately documented as being taken with his left arm, a resident who was sent to the emergency room (ER) was missing documentation from the ER visit, and a resident that was sent to the hospital was missing hospital documentation and the tests and imaging from their medical record. Resident identifiers: 50, 64, and 78. Findings Included: 1. [...]
Inspectors wroteBased on observation, interview and record review it was determined, for 1 out of 41 sampled residents, that 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. Specifically, a Certified Nurse Assistant (CNA)was observed to pick up the oxygen tubing and nasal cannula from the floor and then offered it to the resident to place on their nose and face. Resident identifier 32.
Inspectors wroteBased on observation, interview, and record review it was determined, for 2 out of 41 sampled residents, that the facility did not ensure that the resident right to self-administer medications was determined by the interdisciplinary team (IDT) as clinically appropriate and safe. Specifically, residents reported self administration of medications and no evaluation was completed to determine if this was a safe practice. Resident identifiers: 32 and 79.
Inspectors wroteBased on interview and record review, it was determined, the facility did not immediately consult with the resident's physician when there was need to alter the residents treatment. Specifically, for 1 out of 41 sampled residents, the facility nursing staff did not notify the provider when a resident's blood sugar (BS) was greater than the indicated amount as per the physician order. Resident identifier: 47. Finding Included: Resident 47 was admitted to the facility on [DATE] with diagnoses that included but not limited to spina bifida, type two diabetes mellitus with hyperglycemia, muscle weakness, bladder disorder, anxiety disorder, chronic pain, essential hypertension, and a colostomy. Resident 47's medical record was reviewed on 2/7/23 Resident 47's care plan was reviewed and revealed a care area with a focus area stating resident has diabetes mellitus type 2 with hyperglycemia. [...]
Inspectors wroteBased on interview and record review it was determined, for 2 out of 41 sampled residents, that the facility did not ensure that residents had the right to be free from abuse, neglect, and misappropriation of property. Specifically, the facility did not protect two residents from abuse by another resident. Resident identifier 2, 3, and 183.
Inspectors wroteBased on interview and record review it was determined for, 1 of 41 sampled residents, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this to the maximum extent practicable to avoid duplicative testing and effort. Specifically, a resident who was assessed as needing a PASARR Level II evaluation did not have a PASARR Level II evaluation. Resident identifier: 50 Findings Include: [...]
Inspectors wroteBased on interview and record review, it was determined, the facility did not provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene to residents who were unable to carry out activities of daily living (ADLs). Specifically, for 2 of 41 sampled residents, two dependent residents did not receive showers or bathing assistance in a timely manner and according to the facility schedule for showers. Resident identifiers: 24 and 133.
Inspectors wroteBased on interview and record review it was determined, for 1 out of 41 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices. Specifically, hospice communication notes were not contained within the resident's medical records and staff reported difficulty with communication between the hospice providers. Resident identifier 32.
Inspectors wroteBased on interview and record review it was determined, for 2 out of 41 sampled residents, that the facility did not ensure that residents who have not used a psychotropic drug were not given the drug unless the medication was necessary to treat a specific condition diagnosed and documented in the clinical record, and residents do not receive psychotropic drugs pursuant to a as needed (PRN) order for greater than 14 days unless the prescribing practitioner has documented a rationale to extend the use with a documented duration for the PRN order. Specifically, a resident received psychotropic medications and monitoring was not documented and another resident had a PRN order for Ativan that extended past 14 days without a documented rationale to extend the use and monitoring was not documented. Resident identifiers: 6 and 11. Findings Included: 1. [...]
Inspectors wroteBased on interview and record review it was determined, for 1 of 41 sampled residents, that the facility did not file in the resident's clinical record signed and dated reports of radiological and other diagnostic services. Specifically, a resident had a venous doppler and electrocardiogram (EKG) ordered and the results were not located in the residents medical records. Resident identifier 20.
Inspectors wroteBased on interview and record review, it was determined, the facility did not provide or obtain routine dental services. Specifically, for 1 out of 41 sampled residents, a resident stated her dentures did not fit and needed to be adjusted. In addition, a dental appointment revealed the resident needed her dentures realigned. Resident identifier: 10.
Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure all professional staff were licensed, certified, or registered in accordance with applicable State laws. Specifically, for 1 out of 41 sampled residents, a nurse with a suspended license was providing patient care and was not following the restrictions on their license. Resident Identifier: 47.
Inspectors wroteBased on interview and record review, it was determined, the facility did not establish an infection prevention and control program that included, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, for 2 out of 41 sampled residents, a resident with a urinary tract infection (UTI) was not treated for a pathogen that was listed on the urinalysis (UA). In addition, a resident with a UTI was treated with two antibiotics that were not listed on the susceptibility laboratory report. Resident identifiers: 15 and 68.
Inspectors wroteBased on observation and interview, it was determined, the facility did not have the nurse staffing information posted. The facility must post the following information on a daily basis: Facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurse (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants, and the resident census. The facility must post the nurse staffing data on a daily basis at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Additionally, the information must be displayed in a prominent place readily accessible to residents and visitors. Specifically, the nurse staffing information was not completed and readily accessible to residents and visitors.
Inspectors wroteBased on observation, interview and record review it was determined, for 8 of 40 sample residents, that the facility did not provide a safe, clean, comfortable and homelike environment. Specifically, floors were sticky, there were stains on the carpets, bathrooms had missing base boards, fans in the hallway were soiled, a wheelchair was not clean, and there was debris in resident rooms. Resident identifiers: 13, 21, 39, 41, 44, 51, 60 and 65.
Inspectors wroteBased on observation, interview and record review it was determined, for 8 of 40 sampled residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframe's to meet resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. [...]
Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that a resident that had urinary incontinence, based on the resident's comprehensive assessment, received appropriate treatment and services to prevent urinary tract infections. Specifically, a resident was observed saturated with urine for over 4 hours without incontinence cares. Resident identifier: 39.
Inspectors wroteBased on interview and record review it was determined, for 3 out of 35 sampled residents, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any of these combinations. Specifically, medications were not administered per the physician ordered parameters. Resident identifiers: 5, 40, and 182.
Inspectors wroteBased on observation and interview it was determined that the facility did not ensure that all drugs and biological's were labeled in accordance with currently accepted professional principles, were stored under proper temperature controls, and included the expiration date when applicable. Specifically, multi use vials of medications were opened and available for use without a documented open date and medications were expired and still available for use.
Inspectors wroteBased on observation, interview and record review it was determined, for 6 of 40 sampled residents, that each resident did not received food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained of the food quality, resident council minutes revealed complaints of food quality, and a test tray revealed the food was not palatable. Resident identifiers: 50, 60, 62, 69, 76 and 278.
Inspectors wroteBased on observation and interview it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there was outdated and unlabeled food in the refrigerator, there were soiled areas in the kitchen, and food was transported uncovered through the hallways.
Inspectors wrote3. Resident 24 was admitted to the facility on [DATE] with diagnoses which included nondisplaced fracture of right femur, atrial fibrillation, cerebral infarction, dementia without behavioral disturbance, muscle weakness, dysphagia and lupus. On 7/13/21 at 9:57 AM, an observation was made of resident 24. Resident 24 was observed to be agitated and yelling she was going to kill Certified Nurse Assistant (CNA) 2. CNA 2 stated resident 24 did not have pressure ulcers. Resident 24's medical record was reviewed on 7/14/21. A hospice form titled RN (Registered Nurse) - Skilled Nursing Visit revealed a hospice note dated 6/18/21. The note revealed She has a healing unstageable wound on right buttocks and is on a hospital bed with pressure relief mattress. Wound improving somewhat per staff and aide report. No other hospice notes were located in resident 24's medical record. [...]
Inspectors wroteBased on observation, interview and record review, it was determined, that the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections, including properly preventing and/or containing COVID-19. [...]
Inspectors wroteBased on observation and interview it was determined that the facility did not have adequate outside ventilation by means of window, or mechanical ventilation, or a combination of the two. Specifically, there were odors throughout the facility during the survey.
Inspectors wroteBased on interview and record review it was determined, for 2 of 40 sample residents, that the facility did not ensure each resident exercised their rights as a resident of the facility. Specifically, residents wanted to go to the grocery store and were not provided instruction on the process. Resident identifiers: 30 and 51.
Inspectors wroteBased on interview and record review it was determined, for 2 of 40 sampled residents, that the facility did not inform each resident periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, a resident was not issued a Notice of Medicare Non-coverage (NOMNC) when the Medicare part A services were terminated and another resident did not have a signed copy of a NOMNC in their medical record. Resident identifiers: 128 and 129.
Inspectors wroteBased on observation, interview and record review it was determined, for 5 of 40 sample residents, that the facility did not ensure each resident had the right to be free from abuse and neglect. Specifically, the facility did not protect residents from another resident. Resident identifiers: 14, 17, 44, 45 and 51.
Inspectors wroteBased on interview and record review it was determined, for 2 of 40 sample residents, that in response to allegations of abuse, exploitation, or mistreatment, the facility failed to have evidence that all alleged violations were thoroughly investigated and prevented. Specifically, there was an allegation of physical abuse that were not thoroughly investigated, was not identified as abuse in the final investigation report, and residents were not protected. Resident identifier: 17 and 45.
Inspectors wroteBased on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that when the facility transferred a resident the receiving health care institution or provider received contact information for the practitioner responsible for the care of the resident, resident representative information including contact information, advance directive information, comprehensive care plan goals, all other necessary information for ongoing care, and a copy of the discharge summary to ensure a safe and effective transition of care. Specifically, a resident was transferred to the hospital without any transfer or discharge paperwork. Resident identifier 5.
Inspectors wroteBased on interview and record review it was determined, for 1 of 40 sample residents, that the facility did not coordinate assessments with the pre-admission screening and resident review (PASARR) program. Including referring all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Specifically, after a resident was diagnosed with a mental illness there was no referral for a level II. Resident identifier: 35.
Inspectors wroteBased on observation, interview and record review, it was determined, for 1 of 40 sample residents, that the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care. Specifically, a resident did not have a baseline care plan regarding assistance with eating, therapy or dietary needs. Resident identifier: 228.
Inspectors wroteBased on observation, interview and record review it was determined, for 2 of 40 sample residents, that the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, one resident who was admitted for alcohol detoxification was drinking alcohol repeatedly without intervention and one resident who had urosepsis had a delay in treatment and required hospitalization. Resident identifiers: 40 and 43.
Inspectors wroteBased on observation, interview, and record review it was determined, for 2 of 40 sampled residents, the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision to prevent accidents. Specifically, a resident was not properly assessed to smoke independently and another resident was not provided adequate supervision while intoxicated and was allowed to continually leave facility unsupervised. Resident identifiers: 52 and 78.
Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that a resident who needed respiratory care was provided care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences. Specifically, a resident who required a Continuous Positive Airway Pressure (CPAP) machine was not provided the machine. Resident identifier: 60.
Inspectors wroteBased on observation, interview, and record review it was determined, for 2 of 40 sample residents, that the facility did not provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being. Specifically, a resident who was in crisis and abused another resident was not provided behavioral health services in the facility and was not provided interventions to avoid another crisis. Resident identifiers: 17 and 45.
Inspectors wroteBased on interview and record review it was determined, for 3 out of 40 sampled residents, that the facility did not ensure that residents who have not used a psychotropic drug were not given the drug unless the medication was necessary to treat a specific condition diagnosed and documented in the clinical record, and residents do not receive psychotropic drugs pursuant to a as needed (PRN) order for greater than 14 days unless the prescribing practitioner has documented a rationale to extend the use with a documented duration for the PRN order. Additionally, an unnecessary drug was any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any of these combinations. [...]
Inspectors wroteBased on interview and record review it was determined, for 1 out of 40 sample residents, that the facility did not ensure that resident's laboratory reports were filed in the clinical record. Specifically, a resident had orders for laboratory reports that were not be located in the medical records. Resident identifier 5.
Inspectors wroteBased on interview and record review it was determined, for 2 of 40 sampled residents, that the facility did not have a written agreement with hospice that was signed by an authorized representative of the hospice and authorized representative of the LTC facility before hospice care was furnished to any resident. The written agreement must set out at least the following: The services that hospice will provide; The hospice responsibilities for determining the appropriate hospice plan of care; The services the LTC facility will continue to provide based on each resident's plan of care; A communication process; including how the communication was documented between the LTC facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours per day. Resident identifiers: 24 and 182.
25 fire safety citations on file: 8 on May 9, 2024, 10 on February 14, 2023, 7 on July 15, 2021.
| Date | Penalty | Amount or length |
|---|---|---|
| October 24, 2025 | Fine | $87,712 |
| May 9, 2024 | Fine | $51,503 |
| November 6, 2023 | Fine | $2,797 |
| October 30, 2023 | Fine | $2,447 |
| October 10, 2023 | Fine | $5,244 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Utah | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.63 | 4.09 | 3.86 |
| Registered nurses | 0.89 | 1.25 | 0.69 |
| All nursing staff on weekends | 3.21 | 3.58 | 3.42 |
| Nurse aides | 2.22 | ||
| Licensed practical nurses | 0.51 | ||
| Nursing staff turnover (share who left in a year) | 58.6% | 50.7% | 45.8% |
| Registered nurse turnover | 53.8% | 40.6% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.91 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.79 on weekdays and 3.21 on weekends, 15% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.7% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.63 in April to June 2025 to 3.63 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.63 | 0.89 | 3.79 | 3.21 | 0.7% | 0 of 90 | 60 |
| Oct to Dec 2025 | 3.44 | 0.84 | 3.62 | 2.97 | 1.2% | 0 of 92 | 71 |
| Jul to Sep 2025 | 3.42 | 0.72 | 3.62 | 2.91 | 1.0% | 1 of 92 | 70 |
| Apr to Jun 2025 | 3.63 | 0.76 | 3.85 | 3.09 | 0.6% | 0 of 91 | 63 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Utah, Jan to Mar 2026 | 3.91 | 1.11 | 4.10 | 3.44 | 2.8% | 0.2% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Utah, all employers | |||
| CNAs (nursing assistants) | $19.15 | $17.81 to $21.32 | 12,260 |
| LPNs and LVNs | $30.40 | $25.71 to $35.86 | 1,680 |
| Registered nurses | $40.67 | $38.49 to $50.54 | 27,420 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Utah | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 18.8 | 11.3 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.7 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 2.6 | 1.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.6 | 2.5 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.8 | 0.9 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 20.6 | 15.1 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 6.6 | 3.9 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 1.0 | 14.2 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 13.9 | 16.6 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 13.4 | 11.6 | 12.0 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Mt. Olympus Rehabilitation Center's Medicare short-stay residents. How to read these, and what Medicare pays for.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 51.5% · Utah: 40 better, 0 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 14 eligible stays.
11.7% this home
No different from the national rate
US median of homes 10.7% · Utah: 3 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 26 eligible stays.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
US median of homes 7.1% · Utah: 2 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 9 eligible stays.
83.3% this home
Median of homes: Utah63.5% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 24 residents counted.
0.0% this home
Median of homes: Utah0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 28 residents counted.
0.0% this home
Median of homes: Utah1.3% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 28 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Utah100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 7 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: BEAVER VALLEY HOSPITAL. CMS links this home to Cascades Healthcare, a group of 19 nursing homes averaging 2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| McSpadden, Darin | Managing control - governing body | Individual | 01/01/2023 | |
| Langford, Scott | Corporate officer | Individual | 09/18/2018 | |
| McSpadden, Darin | Corporate officer | Individual | 09/18/2018 | |
| Cascades at Mount Olympus Rehab LLC | Operational/managerial control | Organization | 09/01/2018 | |
| Cascades Healthcare LLC | Operational/managerial control | Organization | 01/01/2023 | |
| Fullmer, Braden | Operational/managerial control | Individual | 07/01/2024 | |
| Fullmer, Chad | Operational/managerial control | Individual | 09/18/2018 | |
| Langford, Scott | Operational/managerial control | Individual | 09/18/2018 | |
| McSpadden, Darin | Operational/managerial control | Individual | 09/18/2018 | |
| Muir, Garth | Operational/managerial control | Individual | 01/01/2023 | |
| Cascades Healthcare LLC | Adp of the SNF | Organization | 06/04/2025 | |
| Fullmer, Braden | Adp of the SNF | Individual | 07/25/2024 | |
| Fullmer, Chad | Adp of the SNF | Individual | 09/18/2018 | |
| McSpadden, Darin | Adp of the SNF | Individual | 01/01/2023 | |
| Muir, Garth | Adp of the SNF | Individual | 01/01/2023 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Utah. NursingHomeClear cannot take or act on complaints.