Overall Score
CMS Five-Star Quality 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 point1★−1.8 vs UT avg
- StaffingCan add or remove a star2★−1.1 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.
- Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among 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 turnover2★Above only 12% 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 staff2.21hrsAbove only 1% 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 only0.78hrsAbove only 23% 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 better51%Above 54% of peersUT avg52%RN turnover46%
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$25,441Above only 29% of peersUT avg$26,227Fines · denials1 · 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 monthSep 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 31, 2025Cycle 1worst J · immediate jeopardy$25,441
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Apr 11, 2025
- 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 RightsD · isolatedCorrected Apr 11, 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 Apr 11, 2025
- F770Provide timely, quality laboratory services/tests to meet the needs of residents.AdministrationD · isolatedCorrected Apr 11, 2025
- F775Keep complete, dated laboratory records in the resident's record.AdministrationE · patternCorrected Apr 11, 2025
- F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryD · isolatedCorrected Apr 11, 2025
- 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 Apr 11, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Apr 11, 2025
- F924Put firmly secured handrails on each side of hallways.EnvironmentalE · patternCorrected Apr 11, 2025
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Resident RightsD · isolatedCorrected Apr 11, 2025
- 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 11, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Apr 11, 2025
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationJ · isolatedCorrected Apr 11, 2025
Jun 15, 2023Cycle 2worst D · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Aug 4, 2023
- F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareD · isolatedCorrected Aug 4, 2023
Sep 30, 2021Cycle 3worst E · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Nov 18, 2021
- 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 Nov 19, 2021
- F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningE · patternCorrected Dec 10, 2021
- F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareE · patternCorrected Nov 19, 2021
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Dec 10, 2021
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Dec 10, 2021
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Dec 10, 2021
- F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryD · isolatedCorrected Dec 10, 2021
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Nov 15, 2021
- F825Provide or get specialized rehabilitative services as required for a resident.Quality of Life and CareD · isolatedCorrected Dec 10, 2021
- F840Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.AdministrationD · isolatedCorrected Dec 10, 2021
- Assure that each residentâs assessment is updated at least once every 3 months.Resident Assessment and Care PlanningE · patternCorrected Dec 10, 2021
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined2.21hrs
- Registered nursesRN hours only0.78hrs
- Licensed practical nursesLPN hours0.07hrs
- Nurse aidesCNA hours1.36hrs
- Weekend nursingAll staff on Saturdays and Sundays1.87hrs
- Utah average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better51%Above 54% of peersUT avg 52%
- RN turnoverRegistered nurses only46%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy61 certified beds · ~60 residents a day98%Top 4%UT avg 74%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $25,441In fines
- 1Fine
- 0Payment denials
- $26,227UT avg in fines
Actions on record
- Mar 31, 2025Civil money penalty$25,441
Ownership
As filed with CMSStructure
- Ownership type
- Government - City/county
- Chain
- Beaver Valley Hospital5 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
- Beaver Valley Hospital
- Cottonwood Healthcare LLC
- Millcreek Rehabilitation and Nursing LLC
- Brendan Clark
- Walter Myers
- Rachael Stubbs
- 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 465185 · 3520 South Highland Drive, Salt Lake City, UT, 84106.
- 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.
