Cycle 1
Health 2025-01-08 · Fire 2025-01-08
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Layton, UT
Fairfield Village Rehabilitation
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1203 North Fairfield Road, Layton, UT
(801) 807-0113
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
36
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-12-02
CMS approved date
Coverage
Medicare
Participation flags
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
0.46
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.40
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.40
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
0.86
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.02
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
2.99
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
94%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
315
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
73.53
Composite VBP score used to determine payment impact.
Payment multiplier
1.0239
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.05
Baseline 16.87% · Performance 17.70% · Measure score 8.05 · Achievement 8.05 · Improvement 0
Healthcare-associated infections
10
Baseline 3.95% · Performance 4.60% · Measure score 10 · Achievement 10 · Improvement 0
Total nurse turnover
7.42
Baseline 54.80% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 6.67
Adjusted total nurse staffing
3.93
Baseline 4.98 hours · Performance 4.20 hours · Measure score 3.93 · Achievement 3.93 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.8% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 457 · Observed rate 7.22% · Lower 95% interval 7.35% |
| Discharge to community | 62.05% |
50.57%
11.5 pts better
|
Better than the National Rate · Eligible stays 416 · Observed rate 66.11% · Lower 95% interval 57.77% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98% |
95.27%
2.7 pts better
|
Numerator 294 · Denominator 300 |
| Falls with major injury | 1.67% |
0.77%
0.9 pts worse
|
Numerator 5 · Denominator 300 |
| Discharge self-care score | 75.68% |
53.69%
22 pts better
|
Numerator 168 · Denominator 222 |
| Discharge mobility score | 73.87% |
50.94%
22.9 pts better
|
Numerator 164 · Denominator 222 |
| Pressure ulcers or injuries, new or worsened | 2% |
2.29%
0.3 pts better
|
Numerator 6 · Denominator 300 · Adjusted rate 2.61% |
| Healthcare-associated infections requiring hospitalization | 4.6% |
7.12%
2.5 pts better
|
Better than the National Rate · Eligible stays 275 · Observed rate 1.82% · Lower 95% interval 2.85% |
| Staff COVID-19 vaccination coverage | 4.27% |
8.2%
3.9 pts worse
|
Numerator 5 · Denominator 117 |
| Staff flu vaccination coverage | 21.8% |
42%
20.2 pts worse
|
Numerator 29 · Denominator 133 |
| Discharge function score | 74.77% |
56.45%
18.3 pts better
|
Numerator 166 · Denominator 222 |
| Transfer of health information to provider | 99.21% |
95.95%
3.3 pts better
|
Numerator 252 · Denominator 254 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 39 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 40% |
25.2%
14.8 pts better
|
Numerator 64 · Denominator 160 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
93.3%
4.3 pts better
|
81.7%
15.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 97.9% · Q3 97.8% · Q4 97.6% · 4Q avg 97.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
11.8%
4.4 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 7.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
0.9%
0.3 pts worse
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 1.6% · Q4 2.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
91.0%
2.8 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.1% |
17.4%
2.7 pts worse
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 17.9% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-31 · Fire 2023-05-31
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-10-06 · Fire 2021-10-06
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-08
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-02-19
E · Potential for more than minimal harm
2023-05-31
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-06-15
D · Potential for more than minimal harm
2023-05-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-15
E · Potential for more than minimal harm
2021-10-06
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2021-10-25
D · Potential for more than minimal harm
2021-10-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-10-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-08
F758 · Pharmacy Service Deficiencies
Health
Implement 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.
Corrected 2025-01-31
E · Potential for more than minimal harm
2025-01-08
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 2025-01-31
E · Potential for more than minimal harm
2025-01-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-08
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-08
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-01-31
D · Potential for more than minimal harm
2025-01-08
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-01-31
E · Potential for more than minimal harm
2021-10-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-26
D · Potential for more than minimal harm
2021-10-06
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2021-10-21
Penalties and ownership
What sits behind the stars
Ownership
Chp Trs Holding Inc
5% Or Greater Direct Ownership Interest · Organization
Cnl Healthcare Properties Inc
5% Or Greater Indirect Ownership Interest · Organization
Beus, Michael
Operational/Managerial Control · Individual
Bracco, Tracey
Operational/Managerial Control · Individual
Bracco, Tracey
Corporate Director · Individual
Bracco, Tracey
Corporate Officer · Individual
Duarte, Ixchell
Corporate Officer · Individual
Herrick, Chad
Operational/Managerial Control · Individual
Langhorst, Jodi
Operational/Managerial Control · Individual
Levee, Kathleen
Operational/Managerial Control · Individual
Mauldin, Stephen
Corporate Director · Individual
Mauldin, Stephen
Corporate Officer · Individual
Mcrae, John
Corporate Officer · Individual
Porm, Kristin
Operational/Managerial Control · Individual
Rawls, Anna Catherine
Corporate Officer · Individual
Seneff, James
Corporate Director · Individual
Walker, Kristin
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Rocky Mountain Care- Clearfield
Clearfield, UT
2-star overall rating with 1-star inspections with $58,637 in total fines with 19 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Thatcher Brook Rehabilitation & Care Center
Clearfield, UT
5-star overall rating with 3-star inspections with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Pine View Transitional Rehab
Ogden, UT
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out