Cycle 1
Health 2024-01-11 · Fire 2024-01-11
8 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Ogden, UT
Harrison Pointe Healthcare and Rehabilitation
3-star overall rating with 3-star inspections with 8 recent health deficiencies
3430 Harrison Boulevard, Ogden, UT
(801) 399-5609
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
63
Certified beds
Average residents
49
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1979-04-30
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
0.79
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
1.67
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.22
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.66
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
50%
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
12,031
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.70% · Performance 21.62% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.04
Baseline 5.80% · Performance 6.93% · Measure score 3.04 · Achievement 3.04 · Improvement 0
Total nurse turnover
0.59
Baseline 75.51% · Performance 70.00% · Measure score 0.59 · Achievement 0 · Improvement 0.59
Adjusted total nurse staffing
2.07
Baseline 3.76 hours · Performance 3.67 hours · Measure score 2.07 · Achievement 2.07 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.17% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 8.75% · Lower 95% interval 7.02% |
| Discharge to community | 58.68% |
50.57%
8.1 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 55% · Lower 95% interval 46.07% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 87.23% |
95.27%
8 pts worse
|
Numerator 41 · Denominator 47 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 47 |
| Discharge self-care score | 62.5% |
53.69%
8.8 pts better
|
Numerator 20 · Denominator 32 |
| Discharge mobility score | 62.5% |
50.94%
11.6 pts better
|
Numerator 20 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 2.13% |
2.29%
0.2 pts better
|
Numerator 1 · Denominator 47 · Adjusted rate 2% |
| Healthcare-associated infections requiring hospitalization | 6.93% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 8.11% · Lower 95% interval 3.71% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 69 |
| Staff flu vaccination coverage | 39.8% |
42%
2.2 pts worse
|
Numerator 39 · Denominator 98 |
| Discharge function score | 62.5% |
56.45%
6 pts better
|
Numerator 20 · Denominator 32 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · 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 23 |
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 · 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 | 75.8% |
98.0%
22.2 pts worse
|
95.5%
19.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 75.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
2.6%
0.9 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 3.4% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.7% |
16.1%
0.6 pts worse
|
11.4%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 14.3% · Q3 19.2% · Q4 20.7% · 4Q avg 16.7% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
3.8%
1.7 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 0.0% · Q4 3.7% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.3% |
24.1%
3.2 pts worse
|
19.6%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 24.0% · Q3 29.2% · Q4 29.6% · 4Q avg 27.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.1% |
15.4%
2.3 pts better
|
16.7%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 14.3% · Q3 14.3% · Q4 13.0% · 4Q avg 13.1% · 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 | 21.8% |
18.3%
3.5 pts worse
|
16.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.1% |
13.6%
1.5 pts worse
|
14.9%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 33.3% · Q3 9.1% · Q4 3.8% · 4Q avg 15.1% · 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 | 15.5% |
22.4%
6.9 pts better
|
19.8%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 20.9% · Q3 21.4% · Q4 3.5% · 4Q avg 15.5% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
4.1%
1.2 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 8.4% · Q3 3.4% · Q4 3.4% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
93.3%
5.8 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 98.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.7% |
11.8%
4.9 pts worse
|
12.0%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 16.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
0.9%
1.2 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.3% · Q3 2.7% · Q4 1.2% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.0% |
91.0%
4 pts worse
|
79.7%
7.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
17.4%
6.9 pts worse
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 23.3% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-17 · Fire 2022-03-17
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-11-06 · Fire 2019-11-06
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2019-11-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-11-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-09-24
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 2024-11-13
E · Potential for more than minimal harm
2024-01-11
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 2024-02-27
E · Potential for more than minimal harm
2024-01-11
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 2024-02-27
E · Potential for more than minimal harm
2024-01-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-02-27
E · Potential for more than minimal harm
2024-01-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-01-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-01-11
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 2024-02-27
D · Potential for more than minimal harm
2024-01-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-01-11
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-02-27
D · Potential for more than minimal harm
2022-03-17
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2022-04-16
E · Potential for more than minimal harm
2019-11-06
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-12-07
D · Potential for more than minimal harm
2019-11-06
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 2019-11-26
D · Potential for more than minimal harm
2019-11-06
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-11-26
Penalties and ownership
What sits behind the stars
Ownership
Beaver Valley Hospital
Operational/Managerial Control · Organization
Burnam, Soon
Operational/Managerial Control · Individual
Davidson, Craig
Corporate Officer · Individual
Demoisy Healthcare Inc
Operational/Managerial Control · Organization
Gailey, Talisha
Operational/Managerial Control · Individual
Gailey, Talisha
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Crestwood Rehabilitation and Nursing
Ogden, UT
2-star overall rating with 1-star inspections with $20,013 in total fines with 16 recent health deficiencies
#2
Stonehenge of Ogden
Washington Terrace, UT
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Mt Ogden Health and Rehabilitation Center
Washington Terrace, UT
4-star overall rating with 4-star inspections with 5 recent health deficiencies
Jump out