Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- UtahAbove only 34% of peers96 rated homes · average 3.3★
- Salt Lake CountyAbove only 41% of peers35 rated homes · average 3.2★
- United StatesAbove only 41% 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 star3★−0.1 vs UT avg
- Quality measuresCan add or remove a star5★+0.6 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★
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.
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 turnover3★Above only 34% of peersUT avg3.1★U.S. avg2.9★
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.
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 assessments5★Above only 40% of peersUT avg4.4★U.S. avg3.6★
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.
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 staff3.55hrsAbove only 36% of peersUT avg4.05Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
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 only0.68hrsAbove only 16% of peersUT avg1.18Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
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 better45%Above 71% of peersUT avg52%RN turnover25%
The share of nursing staff who left within the past year, from the same payroll data.
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$0Above 53% of peersUT avg$26,227Fines · denials0 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthDec 2021 – Mar 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Mar 24, 2025Cycle 1worst F · no actual harm
- Assure that each residentâs assessment is updated at least once every 3 months.Resident Assessment and Care PlanningE · patternCorrected May 10, 2025
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected May 10, 2025
- F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected May 10, 2025
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected May 10, 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 May 10, 2025
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected May 10, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected May 10, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected May 10, 2025
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected May 10, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected May 10, 2025
- F728Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.Nursing and Physician ServicesD · isolatedCorrected May 10, 2025
Sep 8, 2023Cycle 2worst E · no actual harm
- F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Oct 9, 2023
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Oct 9, 2023
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Oct 9, 2023
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Oct 9, 2023
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Oct 9, 2023
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Oct 9, 2023
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Oct 9, 2023
Dec 16, 2021Cycle 3worst E · no actual harm
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Feb 7, 2022
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Feb 7, 2022
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Feb 7, 2022
- 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 ServiceD · isolatedCorrected Feb 7, 2022
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Feb 7, 2022
- 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 7, 2022
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Feb 7, 2022
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.55hrs
- Registered nursesRN hours only0.68hrs
- Licensed practical nursesLPN hours0.69hrs
- Nurse aidesCNA hours2.18hrs
- Weekend nursingAll staff on Saturdays and Sundays3.16hrs
- Utah average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better45%Above 71% of peersUT avg 52%
- RN turnoverRegistered nurses only25%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy120 certified beds · ~83 residents a day69%Above only 34% of peersUT avg 74%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $0In fines
- 0Fines
- 0Payment denials
- $26,227UT avg in fines
Actions on record
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- The Ensign Group324 facilities in the chain3.2★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Beaver Valley Hospital
- Olympus Health, INC.
- Soon Burnam
- Mark Wallace
- Soon Burnam
- Tyler Moss
- Mark Wallace
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 465109 · 4782 South Holladay Boulevard, 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.
