Cycle 1
Health 2025-06-26 · Fire 2025-06-26
10 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cedar City, UT
Cedar Health and Rehabilitation
2-star overall rating with 2-star inspections with 10 recent health deficiencies
411 West 1325 North, Cedar City, UT
(435) 586-6481
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1996-09-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.65
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.87
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.28
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
4.04
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,613
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.54
Composite VBP score used to determine payment impact.
Payment multiplier
0.9892
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.75
Baseline 18.27% · Performance 20.62% · Measure score 1.75 · Achievement 1.75 · Improvement 0
Healthcare-associated infections
7.2
Baseline 8.11% · Performance 5.71% · Measure score 7.2 · Achievement 7.1 · Improvement 7.2
Total nurse turnover
3.74
Baseline 46.25% · Performance 48.39% · Measure score 3.74 · Achievement 3.74 · Improvement 0
Adjusted total nurse staffing
1.52
Baseline 3.37 hours · Performance 3.51 hours · Measure score 1.52 · Achievement 1.52 · Improvement 0.09
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.41% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 106 · Observed rate 6.6% · Lower 95% interval 7.01% |
| Discharge to community | 52.12% |
50.57%
1.5 pts better
|
No Different than the National Rate · Eligible stays 90 · Observed rate 51.11% · Lower 95% interval 42.8% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 94.52% |
95.27%
0.8 pts worse
|
Numerator 69 · Denominator 73 |
| Falls with major injury | 1.37% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 73 |
| Discharge self-care score | 60.42% |
53.69%
6.7 pts better
|
Numerator 29 · Denominator 48 |
| Discharge mobility score | 37.5% |
50.94%
13.4 pts worse
|
Numerator 18 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 1.37% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 73 · Adjusted rate 2.01% |
| Healthcare-associated infections requiring hospitalization | 5.71% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 72 · Observed rate 1.39% · Lower 95% interval 2.43% |
| Staff COVID-19 vaccination coverage | 5.74% |
8.2%
2.5 pts worse
|
Numerator 7 · Denominator 122 |
| Staff flu vaccination coverage | 33.1% |
42%
8.9 pts worse
|
Numerator 48 · Denominator 145 |
| Discharge function score | 54.17% |
56.45%
2.3 pts worse
|
Numerator 26 · Denominator 48 |
| Transfer of health information to provider | 96.67% |
95.95%
0.7 pts better
|
Numerator 58 · Denominator 60 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 44 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.2
0.5 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.8 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.5
0.3 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.8%
3.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.6% |
98.0%
1.4 pts worse
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
2.6%
1.4 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 5.9% · Q3 1.8% · Q4 1.7% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.7% |
16.1%
4.4 pts better
|
11.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 6.1% · Q3 11.1% · Q4 14.8% · 4Q avg 11.7% |
| Percentage of long-stay residents who lose too much weight | 12.0% |
3.8%
8.2 pts worse
|
5.4%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 8.3% · Q3 25.9% · Q4 11.1% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.2% |
24.1%
9.1 pts worse
|
19.6%
13.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 27.1% · Q3 37.0% · Q4 37.0% · 4Q avg 33.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.8% |
15.4%
5.6 pts better
|
16.7%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.1% · Q3 12.8% · Q4 11.8% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 30.1% |
18.3%
11.8 pts worse
|
16.3%
13.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.1% · Q2 25.6% · Q3 39.0% · Q4 16.0% · 4Q avg 30.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.3% |
13.6%
8.7 pts worse
|
14.9%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.0% · Q2 28.3% · Q3 21.6% · Q4 2.0% · 4Q avg 22.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.8%
1.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.7% |
22.4%
0.7 pts better
|
19.8%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 21.4% · Q3 14.5% · Q4 19.9% · 4Q avg 21.7% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
4.1%
3.6 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
93.3%
1.3 pts better
|
81.7%
12.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.0% · Q2 92.5% · Q3 96.7% · Q4 97.6% · 4Q avg 94.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.8% |
11.8%
2 pts worse
|
12.0%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 13.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
0.9%
0.1 pts worse
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.2% · Q3 0.0% · Q4 1.3% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.5% |
91.0%
10.5 pts worse
|
79.7%
0.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.0% |
17.4%
0.4 pts better
|
23.9%
6.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 15.1% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-13 · Fire 2023-07-13
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-08-19 · Fire 2021-08-19
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2021-08-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-08-19
D · Potential for more than minimal harm
2021-08-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-08-19
Inspection history
Recent health citations
G · Actual harm
2025-06-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-22
E · Potential for more than minimal harm
2025-06-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-22
E · Potential for more than minimal harm
2025-06-26
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-08-22
E · Potential for more than minimal harm
2025-06-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-06-26
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-06-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-06-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-06-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-06-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-06-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-22
E · Potential for more than minimal harm
2023-07-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-07-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-13
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-13
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-13
F761 · Pharmacy Service Deficiencies
Health
Ensure 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.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-13
F779 · Administration Deficiencies
Health
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-25
E · Potential for more than minimal harm
2021-08-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-10-01
D · Potential for more than minimal harm
2021-08-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-10-01
Penalties and ownership
What sits behind the stars
Ownership
Beaver Valley Hospital
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Cedar City Healthcare, Inc.
Operational/Managerial Control · Organization
Dart, Grayson
Operational/Managerial Control · Individual
Eaton, Spencer
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Moss, Tyler
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Stonehenge of Cedar City
Cedar City, UT
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Garfield County Nursing Home
Panguitch, UT
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Hurricane Health and Rehabilitation
Hurricane, UT
2-star overall rating with 2-star inspections with $46,602 in total fines with 7 recent health deficiencies
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