Cycle 1
Health 2025-03-24 · Fire 2025-03-24
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Salt Lake City, UT
Holladay Healthcare Center
3-star overall rating with 2-star inspections with 11 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
4782 South Holladay Boulevard, Salt Lake City, UT
(801) 277-7002
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
120
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1987-02-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.68
Registered nurse staffing
LPN hours / resident day
0.69
Licensed practical nurse staffing
Aide hours / resident day
2.18
Nurse aide staffing
Weekend hours
3.16
Weekend nurse staffing
RN turnover
25%
Annual RN turnover
Total nurse turnover
45%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.5
1 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
96.8%
2.8 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
98.0%
0.5 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
2.6%
1.4 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
16.1%
14.2 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 10.9% |
3.8%
7.1 pts worse
|
5.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.9% |
24.1%
4.2 pts better
|
19.6%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 9.7% |
15.4%
5.7 pts better
|
16.7%
7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.6% |
18.3%
4.3 pts worse
|
16.3%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.4% |
13.6%
1.8 pts worse
|
14.9%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
0.9%
1.2 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.8%
0.4 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.6% |
22.4%
9.2 pts worse
|
19.8%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
4.1%
2.1 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
93.3%
5.5 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
11.8%
4 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
0.9%
About the same
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.7% |
91.0%
3.7 pts better
|
79.7%
15 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.5% |
17.4%
0.9 pts better
|
23.9%
7.4 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-08 · Fire 2023-09-08
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2021-12-16 · Fire 2021-12-16
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-03-24
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-03-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-03-24
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 2025-04-11
E · Potential for more than minimal harm
2023-09-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-09
F · Potential for more than minimal harm
2021-12-16
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-02-04
D · Potential for more than minimal harm
2021-12-16
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-02-04
D · Potential for more than minimal harm
2021-12-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-02-04
D · Potential for more than minimal harm
2021-12-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-02-04
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-24
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 2025-05-10
E · Potential for more than minimal harm
2025-03-24
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-05-10
E · Potential for more than minimal harm
2025-03-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-05-10
E · Potential for more than minimal harm
2025-03-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-10
D · Potential for more than minimal harm
2025-03-24
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-05-10
D · Potential for more than minimal harm
2025-03-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-10
D · Potential for more than minimal harm
2025-03-24
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 2025-05-10
D · Potential for more than minimal harm
2025-03-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-10
D · Potential for more than minimal harm
2025-03-24
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2025-05-10
D · Potential for more than minimal harm
2025-03-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-10
D · Potential for more than minimal harm
2025-03-24
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 2025-05-10
E · Potential for more than minimal harm
2023-09-08
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 2023-10-09
E · Potential for more than minimal harm
2023-09-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-09
D · Potential for more than minimal harm
2023-09-08
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-10-09
D · Potential for more than minimal harm
2023-09-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-09
D · Potential for more than minimal harm
2023-09-08
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 2023-10-09
D · Potential for more than minimal harm
2023-09-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-09
D · Potential for more than minimal harm
2023-09-08
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 2023-10-09
E · Potential for more than minimal harm
2021-12-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-02-07
E · Potential for more than minimal harm
2021-12-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-07
D · Potential for more than minimal harm
2021-12-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-02-07
D · Potential for more than minimal harm
2021-12-16
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 2022-02-07
D · Potential for more than minimal harm
2021-12-16
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 2022-02-07
D · Potential for more than minimal harm
2021-12-16
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 2022-02-07
D · Potential for more than minimal harm
2021-12-16
F811 · Nutrition and Dietary Deficiencies
Health
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Corrected 2022-02-07
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
Moss, Tyler
Corporate Officer · Individual
Olympus Health, Inc.
Operational/Managerial Control · Organization
Wallace, Mark
Operational/Managerial Control · Individual
Wallace, Mark
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
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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
Highland Care Center
Holladay, UT
5-star overall rating with 4-star inspections with 5 recent health deficiencies
#3
Monument Healthcare Millcreek
Salt Lake City, UT
4-star overall rating with 3-star inspections with 10 recent health deficiencies
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