Cycle 1
Health 2024-11-21 · Fire 2024-11-21
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
St. George, UT
Coral Desert Rehabilitation and Care
5-star overall rating with 4-star inspections with 2 recent health deficiencies
1490 East Foremaster Drive, St. George, UT
(435) 674-5195
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2005-02-03
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.62
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.66
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
5.07
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
2.41
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.49
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.28
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.09
CMS adjusted RN staffing hours
Adjusted total hours
3.40
CMS adjusted total nurse staffing hours
Case-mix index
2.04
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,017
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9848
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.83
Baseline 19.74% · Performance 18.27% · Measure score 6.83 · Achievement 6.83 · Improvement 4.92
Healthcare-associated infections
3.74
Baseline 6.20% · Performance 6.72% · Measure score 3.74 · Achievement 3.74 · Improvement 0
Total nurse turnover
0
Baseline 64.58% · Performance 65.48% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.66
Baseline 3.86 hours · Performance 3.26 hours · Measure score 0.66 · Achievement 0.66 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.82% |
10.72%
1.9 pts better
|
Better than the National Rate · Eligible stays 512 · Observed rate 6.84% · Lower 95% interval 7.02% |
| Discharge to community | 72.06% |
50.57%
21.5 pts better
|
Better than the National Rate · Eligible stays 456 · Observed rate 73.25% · Lower 95% interval 67.24% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 262 · Denominator 262 |
| Falls with major injury | 0.38% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 262 |
| Discharge self-care score | 59.22% |
53.69%
5.5 pts better
|
Numerator 122 · Denominator 206 |
| Discharge mobility score | 68.93% |
50.94%
18 pts better
|
Numerator 142 · Denominator 206 |
| Pressure ulcers or injuries, new or worsened | 1.91% |
2.29%
0.4 pts better
|
Numerator 5 · Denominator 262 · Adjusted rate 2.5% |
| Healthcare-associated infections requiring hospitalization | 6.72% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 245 · Observed rate 5.71% · Lower 95% interval 4.42% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 136 |
| Staff flu vaccination coverage | 21.35% |
42%
20.6 pts worse
|
Numerator 41 · Denominator 192 |
| Discharge function score | 68.45% |
56.45%
12 pts better
|
Numerator 141 · Denominator 206 |
| Transfer of health information to provider | 97.73% |
95.95%
1.8 pts better
|
Numerator 43 · Denominator 44 |
| Transfer of health information to patient | 99.04% |
96.28%
2.8 pts better
|
Numerator 206 · Denominator 208 |
| Resident COVID-19 vaccinations up to date | 10.16% |
25.2%
15 pts worse
|
Numerator 13 · Denominator 128 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who lose too much weight | 3.4% |
3.8%
0.4 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 0.0% |
24.1%
24.1 pts better
|
19.6%
19.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| 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 · 4Q avg 0.0% |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
1.8%
1.6 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with pressure ulcers | 25.8% |
4.1%
21.7 pts worse
|
5.1%
20.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
93.3%
4 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 96.7% · Q3 97.3% · Q4 97.9% · 4Q avg 97.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.0% |
11.8%
4.2 pts worse
|
12.0%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 15.2% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
0.9%
0.4 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.8% |
91.0%
0.8 pts better
|
79.7%
12.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.3% |
17.4%
2.1 pts better
|
23.9%
8.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.3% · Observed 12.6% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-15 · Fire 2022-12-15
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-05-06 · Fire 2021-05-06
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-06
E · Potential for more than minimal harm
2022-12-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-01-31
E · Potential for more than minimal harm
2022-12-15
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 2023-01-31
E · Potential for more than minimal harm
2022-12-15
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 2023-01-31
E · Potential for more than minimal harm
2022-12-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-31
D · Potential for more than minimal harm
2022-12-15
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 2023-01-31
D · Potential for more than minimal harm
2022-12-15
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 2023-01-31
D · Potential for more than minimal harm
2022-12-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-01-31
D · Potential for more than minimal harm
2022-12-15
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-01-31
D · Potential for more than minimal harm
2022-12-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-31
D · Potential for more than minimal harm
2022-12-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-01-31
D · Potential for more than minimal harm
2022-12-15
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2023-01-31
Penalties and ownership
What sits behind the stars
Ownership
Milestone Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Hoopes, Tyler
Operational/Managerial Control · Individual
Hoopes, Tyler
Corporate Director · Individual
Hoopes, Tyler
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Advanced Health Care of St. George
St George, UT
5-star overall rating with 4-star inspections with $4,194 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Bella Terra St George
St. George, UT
2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $100,651 in total fines with 56 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
St. George Rehabilitation
St. George, UT
3-star overall rating with 3-star inspections with 8 recent health deficiencies
Jump out