Cycle 1
Health 2024-06-11 · Fire 2024-06-11
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Holladay, UT
Highland Care Center
5-star overall rating with 4-star inspections with 5 recent health deficiencies
4285 South Highland Drive, Holladay, UT
(801) 278-2839
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
103
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Eduro Healthcare
Operator or chain grouping
Approved since
1981-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
36 facilities
Chain averages 2 overall / 3 health / 2 staffing / 3 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
0.44
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.23
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.69
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.24
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
0.91
CMS adjusted RN staffing hours
Adjusted total hours
3.32
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,413
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.21
Baseline 18.53% · Performance 19.95% · Measure score 3.21 · Achievement 3.21 · Improvement 0
Healthcare-associated infections
0.62
Baseline 7.40% · Performance 7.65% · Measure score 0.62 · Achievement 0.62 · Improvement 0
Total nurse turnover
3.37
Baseline 65.85% · Performance 50.00% · Measure score 3.37 · Achievement 3.35 · Improvement 3.37
Adjusted total nurse staffing
0.99
Baseline 3.24 hours · Performance 3.36 hours · Measure score 0.99 · Achievement 0.99 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.7% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 7.08% · Lower 95% interval 6.57% |
| Discharge to community | 54.09% |
50.57%
3.5 pts better
|
No Different than the National Rate · Eligible stays 94 · Observed rate 53.19% · Lower 95% interval 46.04% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 59 · Denominator 59 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 59 |
| Discharge self-care score | 47.83% |
53.69%
5.9 pts worse
|
Numerator 22 · Denominator 46 |
| Discharge mobility score | 60.87% |
50.94%
9.9 pts better
|
Numerator 28 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 3.39% |
2.29%
1.1 pts worse
|
Numerator 2 · Denominator 59 · Adjusted rate 3.36% |
| Healthcare-associated infections requiring hospitalization | 7.65% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 10.17% · Lower 95% interval 4.85% |
| Staff COVID-19 vaccination coverage | 1.63% |
8.2%
6.6 pts worse
|
Numerator 2 · Denominator 123 |
| Staff flu vaccination coverage | 36.36% |
42%
5.6 pts worse
|
Numerator 60 · Denominator 165 |
| Discharge function score | 63.04% |
56.45%
6.6 pts better
|
Numerator 29 · Denominator 46 |
| Transfer of health information to provider | 97.37% |
95.95%
1.4 pts better
|
Numerator 37 · Denominator 38 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 45.45% |
25.2%
20.3 pts better
|
Numerator 15 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.2
0.6 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.5
0.4 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.5 · 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 | 2.9% |
2.6%
0.3 pts worse
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.7% · Q3 3.4% · Q4 3.1% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
16.1%
15.7 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
3.8%
1 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 0.0% · Q3 1.9% · Q4 1.9% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.9% |
24.1%
1.8 pts worse
|
19.6%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 30.2% · Q3 20.8% · Q4 19.6% · 4Q avg 25.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.6% |
15.4%
5.8 pts better
|
16.7%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 10.5% · Q3 7.5% · Q4 12.5% · 4Q avg 9.6% · 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 | 17.1% |
18.3%
1.2 pts better
|
16.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 25.4% · Q3 12.0% · Q4 14.4% · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.7% |
13.6%
7.9 pts better
|
14.9%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.6% · Q3 3.8% · Q4 9.1% · 4Q avg 5.7% · 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 | 0.8% |
1.8%
1 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.4% |
22.4%
About the same
|
19.8%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 19.2% · Q3 33.0% · Q4 14.5% · 4Q avg 22.4% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
4.1%
1.1 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.1% · Q3 4.7% · Q4 7.1% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
93.3%
3.7 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.1% · Q2 96.5% · Q3 100.0% · Q4 96.3% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.9% |
11.8%
6.9 pts better
|
12.0%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.9% · Observed 4.8% · Expected 10.9% · 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 | 97.4% |
91.0%
6.4 pts better
|
79.7%
17.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 5.8% |
17.4%
11.6 pts better
|
23.9%
18.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.8% · Observed 4.8% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-16 · Fire 2022-03-16
8 health deficiencies
Top issue: Infection Control (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2019-11-07 · Fire 2019-11-07
12 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-03-16
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-04-29
D · Potential for more than minimal harm
2022-03-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-04-29
D · Potential for more than minimal harm
2019-11-07
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2020-01-09
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-06-11
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 2024-07-31
D · Potential for more than minimal harm
2024-06-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-11
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 2024-07-31
D · Potential for more than minimal harm
2024-06-11
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-06-11
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 2024-07-31
F · Potential for more than minimal harm
2024-01-02
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 2024-01-25
E · Potential for more than minimal harm
2024-01-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-25
F · Potential for more than minimal harm
2022-03-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-29
E · Potential for more than minimal harm
2022-03-16
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-04-29
D · Potential for more than minimal harm
2022-03-16
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 2022-04-29
D · Potential for more than minimal harm
2022-03-16
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 2022-04-29
D · Potential for more than minimal harm
2022-03-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-04-29
D · Potential for more than minimal harm
2022-03-16
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 2022-04-29
D · Potential for more than minimal harm
2022-03-16
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-04-29
D · Potential for more than minimal harm
2022-03-16
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-04-29
E · Potential for more than minimal harm
2019-11-07
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 2019-12-20
E · Potential for more than minimal harm
2019-11-07
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 2019-12-20
E · Potential for more than minimal harm
2019-11-07
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 2019-12-20
E · Potential for more than minimal harm
2019-11-07
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 2019-12-20
D · Potential for more than minimal harm
2019-11-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-12-20
D · Potential for more than minimal harm
2019-11-07
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-12-20
D · Potential for more than minimal harm
2019-11-07
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 2019-12-20
D · Potential for more than minimal harm
2019-11-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-12-20
D · Potential for more than minimal harm
2019-11-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-12-20
D · Potential for more than minimal harm
2019-11-07
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 2019-12-20
Penalties and ownership
What sits behind the stars
Ownership
Beaver Valley Hospital
5% Or Greater Direct Ownership Interest · Organization
Bewsey, Michael
Corporate Officer · Individual
Davidson, Craig
Operational/Managerial Control · Individual
Davidson, Craig
Corporate Officer · Individual
Eduro Healthcare LLC
Operational/Managerial Control · Organization
Highland Nursing And Rehab Center, LLC
Operational/Managerial Control · Organization
Langford, Scott
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Spring Creek Healthcare Center
Salt Lake City, UT
2-star overall rating with 2-star inspections with $53,472 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Monument Healthcare Millcreek
Salt Lake City, UT
4-star overall rating with 3-star inspections with 10 recent health deficiencies
#3
Holladay Healthcare Center
Salt Lake City, UT
3-star overall rating with 2-star inspections with 11 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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