Cycle 1
Health 2025-09-25 · Fire 2025-09-25
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Hurricane, UT
Hurricane Health and Rehabilitation
2-star overall rating with 2-star inspections with $46,602 in total fines with 7 recent health deficiencies
416 North State Street, Hurricane, UT
(435) 635-9833
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1985-07-01
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.81
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.82
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.24
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.22
CMS adjusted total nurse staffing hours
Case-mix index
1.62
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,248
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.54
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.25
Baseline 20.54% · Performance 18.53% · Measure score 6.25 · Achievement 6.25 · Improvement 5.21
Healthcare-associated infections
0.76
Baseline 8.52% · Performance 8.07% · Measure score 0.76 · Achievement 0 · Improvement 0.76
Total nurse turnover
0
Baseline 61.36% · Performance 75.39% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.27 hours · Performance 3.15 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.86% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 4.12% · Lower 95% interval 5.56% |
| Discharge to community | 63.22% |
50.57%
12.6 pts better
|
Better than the National Rate · Eligible stays 75 · Observed rate 66.67% · Lower 95% interval 53.46% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.01% |
95.27%
1.7 pts better
|
Numerator 65 · Denominator 67 |
| Falls with major injury | 1.49% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 67 |
| Discharge self-care score | 43.9% |
53.69%
9.8 pts worse
|
Numerator 18 · Denominator 41 |
| Discharge mobility score | 48.78% |
50.94%
2.2 pts worse
|
Numerator 20 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 4.48% |
2.29%
2.2 pts worse
|
Numerator 3 · Denominator 67 · Adjusted rate 4.66% |
| Healthcare-associated infections requiring hospitalization | 8.07% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 10.14% · Lower 95% interval 4.63% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 82 |
| Staff flu vaccination coverage | 30.23% |
42%
11.8 pts worse
|
Numerator 39 · Denominator 129 |
| Discharge function score | 60.98% |
56.45%
4.5 pts better
|
Numerator 25 · Denominator 41 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 39 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 23.33% |
25.2%
1.9 pts worse
|
Numerator 7 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
1.2
1.5 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.1 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.8 |
1.5
2.3 pts worse
|
1.8
2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 4.7 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
96.8%
1.8 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 97.2% · Q3 100.0% · Q4 100.0% · 4Q avg 98.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
98.0%
0.4 pts worse
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
2.6%
0.2 pts worse
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.8% · Q3 2.9% · Q4 2.7% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.3% |
16.1%
3.8 pts better
|
11.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 6.7% · Q3 21.2% · Q4 12.1% · 4Q avg 12.3% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
3.8%
3.5 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 9.7% · Q3 3.7% · Q4 12.1% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.8% |
24.1%
5.3 pts better
|
19.6%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 12.5% · Q3 27.6% · Q4 21.2% · 4Q avg 18.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.7% |
15.4%
0.7 pts better
|
16.7%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 21.7% · Q3 16.0% · Q4 4.0% · 4Q avg 14.7% · 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 | 36.9% |
18.3%
18.6 pts worse
|
16.3%
20.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.8% |
13.6%
8.2 pts worse
|
14.9%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.1% · Q2 23.3% · Q3 10.7% · Q4 6.2% · 4Q avg 21.8% · 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 | 2.9% |
1.8%
1.1 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 3.0% · Q4 5.4% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.5% |
22.4%
9.1 pts worse
|
19.8%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.5% · Q2 28.0% · Q3 32.5% · Q4 31.7% · 4Q avg 31.5% |
| Percentage of long-stay residents with pressure ulcers | 0.4% |
4.1%
3.7 pts better
|
5.1%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
93.3%
6.4 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.5% |
11.8%
11.7 pts worse
|
12.0%
11.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 22.8% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
0.9%
0.1 pts worse
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.0%
9 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
17.4%
6.4 pts worse
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 22.8% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-18 · Fire 2023-10-18
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-09-21 · Fire 2022-09-21
3 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2022-09-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-15
Inspection history
Recent health citations
G · Actual harm
2025-09-25
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-11-17
G · Actual harm
2025-09-25
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2025-11-17
E · Potential for more than minimal harm
2025-09-25
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 2025-11-17
D · Potential for more than minimal harm
2025-09-25
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 2025-11-17
D · Potential for more than minimal harm
2025-09-25
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-11-17
D · Potential for more than minimal harm
2025-09-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-11-17
D · Potential for more than minimal harm
2025-09-25
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 2025-11-17
G · Actual harm
2024-07-30
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 2024-04-23
D · Potential for more than minimal harm
2024-03-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-15
E · Potential for more than minimal harm
2023-10-18
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 2023-11-18
E · Potential for more than minimal harm
2023-10-18
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 2023-11-18
D · Potential for more than minimal harm
2023-10-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-18
D · Potential for more than minimal harm
2023-10-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-11-18
E · Potential for more than minimal harm
2022-09-21
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 2022-11-01
E · Potential for more than minimal harm
2022-09-21
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-11-01
D · Potential for more than minimal harm
2022-09-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-01
Penalties and ownership
What sits behind the stars
$38,584
2025-09-25
Fine
Fine · fine $38,584
Fine
$8,018
2024-07-30
Fine
Fine · fine $8,018
Fine
Ownership
Beaver Valley Hospital
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Jenkins, Tracy
Operational/Managerial Control · Individual
Moss, Tyler
Corporate Officer · Individual
Zion Healthcare, Inc.
Operational/Managerial Control · Organization
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#2
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St. George, UT
5-star overall rating with 4-star inspections with 2 recent health deficiencies
#3
Advanced Health Care of St. George
St George, UT
5-star overall rating with 4-star inspections with $4,194 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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