Cycle 1
Health 2024-07-02 · Fire 2024-07-02
12 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.
Roy, UT
Heritage Park Healthcare and Rehabilitation
3-star overall rating with 2-star inspections with abuse icon flag with $36,645 in total fines with 12 recent health deficiencies
2700 West 5600 South, Roy, UT
(801) 825-9731
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
176
Certified beds
Average residents
110
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1978-01-01
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
0.99
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.89
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.56
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
0.78
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
1.72
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,210
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9859
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.23
Baseline 18.71% · Performance 20.86% · Measure score 1.23 · Achievement 1.23 · Improvement 0
Healthcare-associated infections
3.16
Baseline 6.81% · Performance 6.89% · Measure score 3.16 · Achievement 3.16 · Improvement 0
Total nurse turnover
7.78
Baseline 44.44% · Performance 31.90% · Measure score 7.78 · Achievement 7.78 · Improvement 5.90
Adjusted total nurse staffing
0
Baseline 2.98 hours · Performance 2.74 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.92% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 103 · Observed rate 5.83% · Lower 95% interval 6.18% |
| Discharge to community | 48.23% |
50.57%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 91 · Observed rate 41.76% · Lower 95% interval 39.78% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.77% |
95.27%
3.5 pts better
|
Numerator 80 · Denominator 81 |
| Falls with major injury | 1.23% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 81 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 36 · Denominator 63 |
| Discharge mobility score | 58.73% |
50.94%
7.8 pts better
|
Numerator 37 · Denominator 63 |
| Pressure ulcers or injuries, new or worsened | 4.94% |
2.29%
2.7 pts worse
|
Numerator 4 · Denominator 81 · Adjusted rate 3.95% |
| Healthcare-associated infections requiring hospitalization | 6.89% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 64 · Observed rate 7.81% · Lower 95% interval 4.21% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 217 |
| Staff flu vaccination coverage | 48.56% |
42%
6.6 pts better
|
Numerator 135 · Denominator 278 |
| Discharge function score | 73.02% |
56.45%
16.6 pts better
|
Numerator 46 · Denominator 63 |
| Transfer of health information to provider | 88.1% |
95.95%
7.9 pts worse
|
Numerator 37 · Denominator 42 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.26% |
25.2%
20.9 pts worse
|
Numerator 2 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.9 · Expected 3.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.4 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
96.8%
1.1 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 93.9% · Q3 100.0% · Q4 100.0% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
98.0%
0.1 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
2.6%
1 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.0% · Q3 4.0% · Q4 4.1% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.2% |
16.1%
8.9 pts better
|
11.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 6.7% · Q3 4.4% · Q4 5.3% · 4Q avg 7.2% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
3.8%
1.6 pts worse
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 5.4% · Q3 3.2% · Q4 6.5% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 39.2% |
24.1%
15.1 pts worse
|
19.6%
19.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 34.4% · Q3 46.8% · Q4 46.2% · 4Q avg 39.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.1% |
15.4%
11.3 pts better
|
16.7%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.7% · Q3 3.5% · Q4 5.4% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.3% |
0.1%
0.2 pts worse
|
0.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.6% |
18.3%
0.3 pts worse
|
16.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 20.3% · Q3 11.7% · Q4 17.5% · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.0% |
13.6%
7.4 pts worse
|
14.9%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 30.1% · Q3 11.5% · Q4 14.3% · 4Q avg 21.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
0.9%
1.3 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.4% · Q3 2.3% · Q4 1.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.8%
0.8 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.1% · Q3 4.0% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.2% |
22.4%
4.8 pts worse
|
19.8%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 31.7% · Q3 30.8% · Q4 21.0% · 4Q avg 27.2% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.1%
0.8 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.5% · Q3 6.3% · Q4 4.6% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.2% |
93.3%
3.1 pts worse
|
81.7%
8.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.8% · Q2 89.7% · Q3 91.2% · Q4 94.0% · 4Q avg 90.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.3% |
11.8%
5.5 pts better
|
12.0%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.3% · Observed 7.8% · Expected 13.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
0.9%
0.9 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.7% |
91.0%
0.7 pts better
|
79.7%
12 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.9% |
17.4%
0.5 pts better
|
23.9%
7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.9% · Observed 20.3% · Expected 28.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-15 · Fire 2022-11-15
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-04-08 · Fire 2021-04-08
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
G · Actual harm
2024-07-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-04
G · Actual harm
2024-07-02
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 2024-08-04
E · Potential for more than minimal harm
2024-07-02
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 2024-08-04
E · Potential for more than minimal harm
2024-07-02
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-04
E · Potential for more than minimal harm
2024-07-02
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 2024-08-04
D · Potential for more than minimal harm
2024-07-02
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-02
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-08-04
D · Potential for more than minimal harm
2024-07-02
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-08-04
D · Potential for more than minimal harm
2024-07-02
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 2024-08-04
D · Potential for more than minimal harm
2024-07-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-08-04
D · Potential for more than minimal harm
2024-07-02
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-08-04
D · Potential for more than minimal harm
2024-07-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-04
E · Potential for more than minimal harm
2023-10-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-10
G · Actual harm
2022-11-15
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 2022-12-02
D · Potential for more than minimal harm
2022-11-15
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 2022-12-02
D · Potential for more than minimal harm
2022-11-15
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 2022-12-02
D · Potential for more than minimal harm
2022-11-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-15
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 2022-12-02
D · Potential for more than minimal harm
2022-11-15
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-02
F · Potential for more than minimal harm
2021-04-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-05-15
E · Potential for more than minimal harm
2021-04-08
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2021-06-01
E · Potential for more than minimal harm
2021-04-08
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2021-05-15
D · Potential for more than minimal harm
2021-04-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2021-05-15
D · Potential for more than minimal harm
2021-04-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2021-05-15
D · Potential for more than minimal harm
2021-04-08
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 2021-05-15
Penalties and ownership
What sits behind the stars
$36,645
2024-07-02
Fine
Fine · fine $36,645
Fine
Ownership
Beaver Valley Hospital
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Operational/Managerial Control · Individual
Fletcher, Jeff
Operational/Managerial Control · Individual
Fletcher, Jeff
Contracted Managing Employee · Individual
Moss, Tyler
Corporate Officer · Individual
West 5600 Healthcare, Inc.
Operational/Managerial Control · Organization
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