Cycle 1
Health 2025-11-24 · Fire 2025-11-24
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Draper, UT
Draper Rehabilitation and Care Center
4-star overall rating with 4-star inspections with 4 recent health deficiencies
12702 South Fort Street, Draper, UT
(801) 571-2704
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
93
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1983-09-01
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
0.89
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.42
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.57
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
0.91
CMS adjusted RN staffing hours
Adjusted total hours
3.65
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,279
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.80% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.97
Baseline 6.12% · Performance 6.65% · Measure score 3.97 · Achievement 3.97 · Improvement 0
Total nurse turnover
1.86
Baseline 73.91% · Performance 62.34% · Measure score 1.86 · Achievement 0 · Improvement 1.86
Adjusted total nurse staffing
1.14
Baseline 3.46 hours · Performance 3.40 hours · Measure score 1.14 · Achievement 1.14 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.14% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 10.39% · Lower 95% interval 7.43% |
| Discharge to community | 49.92% |
50.57%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 50% · Lower 95% interval 38.46% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 47 · Denominator 47 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 47 |
| Discharge self-care score | 59.46% |
53.69%
5.8 pts better
|
Numerator 22 · Denominator 37 |
| Discharge mobility score | 45.95% |
50.94%
5 pts worse
|
Numerator 17 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 2.13% |
2.29%
0.2 pts better
|
Numerator 1 · Denominator 47 · Adjusted rate 2.06% |
| Healthcare-associated infections requiring hospitalization | 6.65% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 4.17% · Lower 95% interval 3.17% |
| Staff COVID-19 vaccination coverage | 0.77% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 130 |
| Staff flu vaccination coverage | 7.6% |
42%
34.4 pts worse
|
Numerator 13 · Denominator 171 |
| Discharge function score | 48.65% |
56.45%
7.8 pts worse
|
Numerator 18 · Denominator 37 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 29.17% |
25.2%
4 pts better
|
Numerator 7 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
1.2
1.7 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 3.2 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.5
0.8 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.3 · Expected 1.7 · 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 | 100.0% |
98.0%
2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
2.6%
0.6 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 1.9% · Q4 4.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
16.1%
10 pts better
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 11.6% · Q3 6.5% · Q4 0.0% · 4Q avg 6.1% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
3.8%
0.9 pts worse
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.1% · Q3 6.0% · Q4 6.4% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.0% |
24.1%
4.9 pts worse
|
19.6%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 26.5% · Q3 30.0% · Q4 29.8% · 4Q avg 29.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.8% |
15.4%
0.4 pts worse
|
16.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 12.5% · Q3 16.7% · Q4 15.0% · 4Q avg 15.8% · 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 | 21.6% |
18.3%
3.3 pts worse
|
16.3%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.1% |
13.6%
4.5 pts better
|
14.9%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 14.6% · Q3 9.1% · Q4 4.8% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.9%
0.3 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.8%
0.8 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 39.4% |
22.4%
17 pts worse
|
19.8%
19.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.5% · Q2 42.3% · Q3 38.6% · Q4 30.7% · 4Q avg 39.4% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
4.1%
2.9 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 8.2% · Q3 6.4% · Q4 4.6% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
93.3%
4.1 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.3% · Q2 95.1% · Q3 100.0% · Q4 100.0% · 4Q avg 97.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.6% |
11.8%
1.2 pts better
|
12.0%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 11.1% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
0.9%
0.2 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.2% |
91.0%
3.2 pts better
|
79.7%
14.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.4% |
17.4%
1 pts better
|
23.9%
7.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 15.6% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-20 · Fire 2023-09-20
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-12-02 · Fire 2021-12-02
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
G · Actual harm
2025-11-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-01
F · Potential for more than minimal harm
2025-11-24
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 2026-01-01
E · Potential for more than minimal harm
2025-11-24
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-01-01
D · Potential for more than minimal harm
2025-11-24
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 2026-01-01
E · Potential for more than minimal harm
2021-12-02
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 2022-02-02
D · Potential for more than minimal harm
2021-12-02
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 2022-02-02
Penalties and ownership
What sits behind the stars
Ownership
Beaver Valley Hospital
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Davidson, Craig
Corporate Officer · Individual
Moss, Tyler
Operational/Managerial Control · Individual
Moss, Tyler
Corporate Officer · Individual
South Valley Healthcare, Inc.
Operational/Managerial Control · Organization
Wilson, Brent
Operational/Managerial Control · Individual
Wilson, Brent
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
NeuroRestorative
Riverton, UT
2-star overall rating with 2-star inspections with $148,417 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Stonehenge of South Jordan
South Jordan, UT
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Sandy Health and Rehab
Sandy, UT
1-star overall rating with 1-star inspections with $89,798 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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