Overall Score
CMS Five-Star Quality RatingBelow averageCMS Five-Star overall rating
- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- UtahAbove only 11% of peers96 rated homes · average 3.3★
- Salt Lake CountyAbove only 15% of peers35 rated homes · average 3.2★
- United StatesAbove only 20% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point2★−0.8 vs UT avg
- StaffingCan add or remove a star2★−1.1 vs UT avg
- Quality measuresCan add or remove a star2★−2.4 vs UT avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersUT avg2.8★U.S. avg2.8★
What is health inspection rating?
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
Why it matters
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 12% of peersUT avg3.1★U.S. avg2.9★
What is staffing rating?
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
Why it matters
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Lowest tier among peersUT avg4.4★U.S. avg3.6★
What is quality measures rating?
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
Why it matters
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.42hrsAbove only 26% of peersUT avg4.05Benchmark4.10
What is total nurse hours?
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Why it matters
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.91hrsAbove only 42% of peersUT avg1.18Benchmark0.75
What is rn hours?
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
Why it matters
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better68%Above only 12% of peersUT avg52%RN turnover75%
What is nursing staff turnover?
The share of nursing staff who left within the past year, from the same payroll data.
Why it matters
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$66,511Above only 13% of peersUT avg$26,227Fines · denials2 · 1
What is fines in the last three years?
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Why it matters
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cycles99citations
4inspection dates
20actual harm (G–I)
7immediate jeopardy (J–L)
Feb 3, 2025most recent
Citations by monthApr 2022 – Feb 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Click to filter the findings below
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Feb 3, 2025Cycle 1worst E · no actual harm
- F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Resident RightsD · isolatedCorrected Mar 27, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Mar 27, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Mar 27, 2025
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Mar 27, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Mar 27, 2025
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Mar 27, 2025
- F693Ensure 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.Quality of Life and CareD · isolatedCorrected Mar 27, 2025
- F694Provide for the safe, appropriate administration of IV fluids for a resident when needed.Quality of Life and CareD · isolatedCorrected Mar 27, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Mar 27, 2025
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Mar 27, 2025
- F758Implement 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.Pharmacy ServiceE · patternCorrected Mar 27, 2025
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceD · isolatedCorrected Mar 27, 2025
Jan 11, 2024Cycle 2worst G · actual harm$53,472, payment denial
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Feb 12, 2024
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Feb 12, 2024
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceD · isolatedCorrected Feb 12, 2024
- F779Keep signed and dated reports of x-rays and other diagnostic services in the residents record.AdministrationD · isolatedCorrected Feb 12, 2024
- F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and DietaryE · patternCorrected Feb 12, 2024
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Feb 12, 2024
- F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryD · isolatedCorrected Feb 12, 2024
- F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected Feb 12, 2024
- F811Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.Nutrition and DietaryD · isolatedCorrected Feb 12, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Feb 12, 2024
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Feb 12, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Feb 12, 2024
- F881Implement a program that monitors antibiotic use.Infection ControlE · patternCorrected Feb 12, 2024
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareG · isolatedCorrected Feb 12, 2024
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Feb 12, 2024
Mar 13, 2023Cycle 3worst G · actual harm$13,039
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Apr 4, 2023
Apr 13, 2022Cycle 3worst K · immediate jeopardy
- F685Assist a resident in gaining access to vision and hearing services.Quality of Life and CareD · isolatedCorrected Jun 23, 2022
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareJ · isolatedCorrected Jun 23, 2022
- F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and CareG · isolatedCorrected Jun 23, 2022
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareK · patternCorrected Jun 23, 2022
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Jun 23, 2022
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareH · patternCorrected Jun 23, 2022
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Jun 23, 2022
- F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.Nursing and Physician ServicesG · isolatedCorrected Jun 23, 2022
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesH · patternCorrected Jun 23, 2022
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesH · patternCorrected Jun 23, 2022
- F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Nursing and Physician ServicesF · widespreadCorrected Jun 23, 2022
- F732Post nurse staffing information every day.Nursing and Physician ServicesD · isolatedCorrected Jun 23, 2022
- F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareJ · isolatedCorrected Jun 23, 2022
- F741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.Quality of Life and CareH · patternCorrected Jun 23, 2022
- F742Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.Quality of Life and CareG · isolatedCorrected Jun 23, 2022
- F745Provide medically-related social services to help each resident achieve the highest possible quality of life.Quality of Life and CareH · patternCorrected Jun 23, 2022
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Jun 23, 2022
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Jun 23, 2022
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceE · patternCorrected Jun 23, 2022
- F770Provide timely, quality laboratory services/tests to meet the needs of residents.AdministrationG · isolatedCorrected Jun 23, 2022
- F773Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.AdministrationD · isolatedCorrected Jun 23, 2022
- F775Keep complete, dated laboratory records in the resident's record.AdministrationD · isolatedCorrected Jun 23, 2022
- F779Keep signed and dated reports of x-rays and other diagnostic services in the residents record.AdministrationD · isolatedCorrected Jun 23, 2022
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Jun 23, 2022
- F825Provide or get specialized rehabilitative services as required for a resident.Quality of Life and CareD · isolatedCorrected Jun 23, 2022
- F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationH · patternCorrected Jun 23, 2022
- F837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.AdministrationH · patternCorrected Jun 23, 2022
- F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.AdministrationF · widespreadCorrected Jun 23, 2022
- F841Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.Nursing and Physician ServicesH · patternCorrected Jun 23, 2022
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Jun 23, 2022
- F865Have a plan that describes the process for conducting QAPI and QAA activities.AdministrationH · patternCorrected Jun 23, 2022
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationH · patternCorrected Jun 23, 2022
- F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyAdministrationH · patternCorrected Jun 23, 2022
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Jun 23, 2022
- F881Implement a program that monitors antibiotic use.Infection ControlD · isolatedCorrected Jun 23, 2022
- F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Infection ControlF · widespreadCorrected Jun 23, 2022
- F886Perform COVID19 testing on residents and staff.Infection ControlE · patternCorrected Jun 23, 2022
- F887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.Infection ControlE · patternCorrected Jun 23, 2022
- F888Ensure staff are vaccinated for COVID-19Infection ControlE · patternCorrected Jun 23, 2022
- F908Keep all essential equipment working safely.EnvironmentalF · widespreadCorrected Jun 23, 2022
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalE · patternCorrected Jun 23, 2022
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Jun 23, 2022
- F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Freedom from Abuse, Neglect, and ExploitationF · widespreadCorrected Jun 23, 2022
- F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesF · widespreadCorrected Jun 23, 2022
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareK · patternCorrected Jun 23, 2022
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Jun 23, 2022
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareH · patternCorrected Jun 23, 2022
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Jun 23, 2022
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Jun 23, 2022
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jun 23, 2022
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected Jun 23, 2022
- F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsE · patternCorrected Jun 23, 2022
- F567Honor the resident's right to manage his or her financial affairs.Resident RightsE · patternCorrected Jun 23, 2022
- F568Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.Resident RightsE · patternCorrected Jun 23, 2022
- F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Resident RightsD · isolatedCorrected Jun 23, 2022
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsG · isolatedCorrected Jun 23, 2022
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsD · isolatedCorrected Jun 23, 2022
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsE · patternCorrected Jun 23, 2022
- F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsE · patternCorrected Jun 23, 2022
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationK · patternCorrected Jun 23, 2022
- F606Not hire anyone with a finding of abuse, neglect, exploitation, or theft.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Jun 23, 2022
- F608Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Jun 23, 2022
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationK · patternCorrected Jun 23, 2022
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationK · patternCorrected Jun 23, 2022
- F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Resident RightsD · isolatedCorrected Jun 23, 2022
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningG · isolatedCorrected Jun 23, 2022
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Jun 23, 2022
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningE · patternCorrected Jun 23, 2022
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Jun 23, 2022
- F660Plan the resident's discharge to meet the resident's goals and needs.Resident Assessment and Care PlanningE · patternCorrected Jun 23, 2022
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Jun 23, 2022
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.42hrs
- Registered nursesRN hours only0.91hrs
- Licensed practical nursesLPN hours0.27hrs
- Nurse aidesCNA hours2.24hrs
- Weekend nursingAll staff on Saturdays and Sundays2.95hrs
- Utah average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better68%Above only 12% of peersUT avg 52%
- RN turnoverRegistered nurses only75%Not ranked by CMS
- Administrators who leftIn the past year2Leadership changed
- Occupancy92 certified beds · ~84 residents a day91%Above 79% of peersUT avg 74%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $66,511In fines
- 2Fines
- 1Payment denial
- $26,227UT avg in fines
Above only 13% of peersFewer fines than 13% of rated homes in Utah
Actions on record
- Jan 11, 2024Civil money penalty$53,472
- Jan 11, 2024Denial of payment for new admissionsfrom Feb 16, 2024
- Mar 13, 2023Civil money penalty$13,039
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Cascades Healthcare20 facilities in the chain2.0★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
Operational or managerial control
- Beaver Valley Hospital
- Cascades Healthcare LLC
- Gregory Baird
- Chad Fullmer
- Darin McSpadden
- Richard Taylor
Corporate directors
- Janett Barney
- Gary Brown
- Richard Oakden
- Matthew Robinson
- Val Smith
- Craig White
Corporate officers
- Scott Langford
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 465049 · 4600 South Highland Drive, Salt Lake City, UT, 84117.
- Percentiles compare this facility with every rated nursing home in Utah and Salt Lake County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
