South Davis Specialty Care
481 South 400 East, Bountiful, UT 84010 · Davis County · (801) 295-2361
95 certified beds, about 54 residents a day · For profit - Corporation · Medicare and Medicaid since 2017
CMS high performing icon Certified for Medicaid Certified for Medicare
Overall
5 of 5
Health inspections
4 of 5
Staffing
4 of 5
Quality measures
5 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 465187 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on December 11, 2025, inspectors cited 4 health deficiencies (the Utah average is 8.8, the national average 9.2).
Of 9 health citations since December 2021, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 7.93 hours per resident per day, against 4.09 across Utah and 3.86 nationally. Registered nurses accounted for 3.67 of those hours.
52.0% of nursing staff left within the year CMS measured (Utah average 50.7%).
CMS links it to The Ensign Group, an affiliated group of 344 nursing homes.
Health inspections
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.
412/21
111/23
412/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
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 9 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
5D
3E
0F
Potential for minimal harm
0A
0B
0C
December 11, 2025Standard inspection · 4 citations
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the food was not served in a sanitary manner.
- D Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview, and record review, it was determined, for 1 out of 27 sampled residents, the facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. Specifically, one resident was observed to have their head of bed lower than 30 degrees when the tube feeding was being administered. Resident identifier: 8.
- D Keep complete, dated laboratory records in the resident's record.
Inspectors wroteBased on interview, and record review, it was determined for 1 out 27 sampled residents, the facility failed to ensure that in the resident's clinical record laboratory (lab) reports that were dated and contain the name and address of the testing laboratory. Specifically, one resident was missing lab reports in their medical record. Resident Identifier: 25 Findings Included: Resident 25 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia. Review of resident 25's medical record was completed on 12/8/25 through 12/11/25. On 4/17/25, a physician's order for Basic Metabolic Panel (BMP) one time only for pulmonary was marked completed. It should be noted that the lab result for the BMP on 4/17/25, was unable to be located in the medical record. [...]
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, it was determined for 2 out 27 sampled residents, the facility failed to ensure that each resident's medical record was accurately documented and maintained. Specifically, a resident's medical document was located in another resident's medical record. Resident Identifier: 25 and 64. Findings Included: A review of resident 25's medical record was conducted. During the review it had revealed that resident 64's urinalysis with culture and sensitivity with a date of service of 4/15/25, was located in resident 25's medical record. On 12/11/25 at 11:16 am, an interview was conducted with the Medical Records Lead (MRL). The MRL stated every morning the medical records were collected from the nurses' stations at which time they were sorted by name and the date of services. [...]
November 8, 2023Standard inspection, Complaint inspection · 1 citation
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, multiple food items were open to air, not dated and not labeled in the kitchen.
December 6, 2021Standard inspection · 4 citations
- G Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined, for 1 out of 31 sampled residents, that the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident sustained a fracture while receiving Passive Range of Motion (PROM) therapy services and did not receive an x-ray to diagnose the injury or treatment for two additional days after the injury occurred. This was cited at a harm. Resident identifier 25.
- E Provide and implement an infection prevention and control program.
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, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, visitors were not screened upon entrance to the facility, a laundry services staff member was observed to not perform hand hygiene between resident rooms, a staff member was observed in a resident care area without personal protective equipment (PPE), and the blood glucometer machine was not sanitized according to manufacturer requirements. Findings Include: 1. On 12/1/21 at 7:00 AM, the state agency surveyor entered the facility. No staff were present at the entrance, and screening was not conducted of the state agency surveyors. [...]
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review it was determined, for 1 of 31 sample residents, that the facility did not immediately consult with the resident's physician when there was an accident involving the resident which resulted in an injury and had the potential for requiring the physician's intervention. Specifically, a resident sustained a fracture during Passive Range of Motion (PROM) exercises and the physician was not notified for two days following the incident. Resident identifier 25.
- D Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on interview and record review it was determined, for 1 of 31 sample residents, that the facility did not ensure that residents who used psychotropic drugs received a gradual dose reduction (GDR) unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, a resident received an anti-anxiety medication for approximately 21 months without an attempted GDR or a physician documented rationale for why any attempted dose reduction would likely impair the resident's function or exacerbate an underlying medical or psychiatric disorder. Resident identifier 28.
Fire safety inspections
6 fire safety citations on file: 3 on November 8, 2023, 3 on December 6, 2021.
Every fire safety citation6 citations
- F Have an alternate power supply for its alarm system.
- F Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- D Have approved installation, maintenance and testing program for fire alarm systems.
- D Have properly installed electrical wiring and gas equipment.
- D Have simulated fire drills held at unexpected times.
- D Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
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) | 7.93 | 4.09 | 3.86 |
| Registered nurses | 3.67 | 1.25 | 0.69 |
| All nursing staff on weekends | 7.07 | 3.58 | 3.42 |
| Nurse aides | 3.72 | ||
| Licensed practical nurses | 0.55 | ||
| Nursing staff turnover (share who left in a year) | 52.0% | 50.7% | 45.8% |
| Registered nurse turnover | 36.7% | 40.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 8.35 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
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 8.29 on weekdays and 7.07 on weekends, 15% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 7.90 in April to June 2025 to 7.93 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 | 7.93 | 3.67 | 8.29 | 7.07 | 0.0% | 0 of 90 | 54 |
| Oct to Dec 2025 | 7.69 | 3.52 | 8.03 | 6.83 | 0.0% | 0 of 92 | 51 |
| Jul to Sep 2025 | 7.79 | 3.51 | 8.20 | 6.74 | 0.0% | 0 of 92 | 50 |
| Apr to Jun 2025 | 7.90 | 3.60 | 8.37 | 6.73 | 0.0% | 0 of 91 | 49 |
| 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.
Quality measures
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 | 11.4 | 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 | 0.0 | 1.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.7 | 2.5 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 5.9 | 0.9 | 1.6 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.5 | 3.9 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 17.1 | 14.2 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 12.6 | 16.6 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 12.2 | 11.6 | 12.0 |
Owners and operators
Legal business name: HOLBROOK HEALTHCARE LLC. CMS links this home to The Ensign Group, a group of 344 nursing homes averaging 3.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Milestone Healthcare LLC | 5% or greater direct ownership interest | Organization | 100% | 03/22/2024 |
| Burnam, Soon | Managing control - governing body | Individual | 03/22/2024 | |
| Fletcher, Jeff | Managing control - governing body | Individual | 05/01/2024 | |
| Martinez, Mark | Managing control - governing body | Individual | 05/01/2024 | |
| Farnsworth, Stephen | Corporate director | Individual | 03/22/2024 | |
| Burnam, Soon | Corporate officer | Individual | 03/22/2024 | |
| Keetch, Chad | Corporate officer | Individual | 03/01/2011 | |
| Fletcher, Jeff | Operational/managerial control | Individual | 05/01/2024 | |
| Martinez, Mark | Operational/managerial control | Individual | 05/01/2024 | |
| Port, Barry | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 07/10/2025 | |
| Ensign Services Inc | Adp of the SNF | Organization | 03/22/2024 | |
| Millcreek Health Holdings LLC | Adp of the SNF | Organization | 03/22/2024 | |
| Standard Bearer Healthcare Op, LP | Adp of the SNF | Organization | 03/22/2024 | |
| The Ensign Group Inc | Adp of the SNF | Organization | 03/22/2024 | |
| Fletcher, Jeff | Adp of the SNF | Individual | 07/10/2025 | |
| Martinez, Mark | Adp of the SNF | Individual | 07/10/2025 |
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.
Questions to ask on a visit
Chosen from this home's own inspection record.
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 2 problems in this area, most recently on December 11, 2025: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 2 problems in this area, most recently on December 11, 2025: "Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube."
- Who is the administrator and director of nursing, and how long have they been in the job?Inspectors cited 1 problem in this area, most recently on December 11, 2025: "Keep complete, dated laboratory records in the resident's record."
- When is the care plan meeting, and can family attend it?Inspectors cited 1 problem in this area, most recently on December 11, 2025: "Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards."
Other nursing homes nearby
- Monument Healthcare Stonecreek Bountiful, 0.9 mi · 2 of 5 stars · 27 citations
- Monument Healthcare Bountiful Bountiful, 1.9 mi · 3 of 5 stars · 21 citations
- Midtown Manor Salt Lake City, 8.5 mi · 1 of 5 stars · 41 citations
- City Creek Post Acute Salt Lake City, 8.6 mi · 4 of 5 stars · 21 citations
- Maple Ridge Rehabilitation and Nursing Salt Lake City, 8.6 mi · 1 of 5 stars · 29 citations
- William E Christofferson Salt Lake Veterans Home Salt Lake City, 9.2 mi · 5 of 5 stars · 12 citations
- Pine Creek Rehabilitation and Nursing Salt Lake City, 9.2 mi · 3 of 5 stars · 41 citations
- St. Joseph Villa Salt Lake City, 10.8 mi · 3 of 5 stars · 14 citations
Utah contacts for a concern about a nursing home
These are the official offices in Utah. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Utah Department of Health and Human Services, Division of Licensing and Background Checks, Health Facilities Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Utah Long Term Care Ombudsman Program, Division of Aging and Adult Services, 801-538-3910. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Utah DLBC Find a Facility (licensing records and compliance history), where Utah publishes its own records on licensed homes.
Common questions
- What is South Davis Specialty Care's Medicare star rating?
- CMS rates South Davis Specialty Care 5 out of 5 stars overall, with 4 for health inspections, 4 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did South Davis Specialty Care get at its last inspection?
- 4 health deficiencies at the standard inspection on December 11, 2025. The Utah average is 8.8.
- Has South Davis Specialty Care been fined?
- CMS lists no fines in the last three years.
- Does South Davis Specialty Care accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns South Davis Specialty Care?
- CMS lists 16 owners and managers, and links the home to The Ensign Group. Legal business name: HOLBROOK HEALTHCARE LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.