Cycle 1
Health 2025-05-15 · Fire 2025-05-15
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Taylorsville, UT
Legacy Village Rehabilitation
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
3251 West 5400 South, Taylorsville, UT
(801) 613-4600
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
40
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2009-12-21
CMS approved date
Coverage
Medicare
Participation flags
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
1.14
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
4.04
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.45
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
1.10
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.45
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.02
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,349
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9979
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.79
Baseline 18.80% · Performance 20.14% · Measure score 2.79 · Achievement 2.79 · Improvement 0
Healthcare-associated infections
5.13
Baseline 4.15% · Performance 6.30% · Measure score 5.13 · Achievement 5.13 · Improvement 0
Total nurse turnover
10
Performance 19.64% · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.63 hours · Performance 3.12 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.64% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 458 · Observed rate 7.21% · Lower 95% interval 7.47% |
| Discharge to community | 72.89% |
50.57%
22.3 pts better
|
Better than the National Rate · Eligible stays 466 · Observed rate 73.82% · Lower 95% interval 68% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.81% |
95.27%
0.5 pts better
|
Numerator 297 · Denominator 310 |
| Falls with major injury | 0.32% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 309 |
| Discharge self-care score | 75.4% |
53.69%
21.7 pts better
|
Numerator 190 · Denominator 252 |
| Discharge mobility score | 65.08% |
50.94%
14.1 pts better
|
Numerator 164 · Denominator 252 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 310 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.3% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 299 · Observed rate 4.68% · Lower 95% interval 3.71% |
| Staff COVID-19 vaccination coverage | 25.6% |
8.2%
17.4 pts better
|
Numerator 43 · Denominator 168 |
| Staff flu vaccination coverage | 15.93% |
42%
26.1 pts worse
|
Numerator 47 · Denominator 295 |
| Discharge function score | 61.51% |
56.45%
5.1 pts better
|
Numerator 155 · Denominator 252 |
| Transfer of health information to provider | 81.58% |
95.95%
14.4 pts worse
|
Numerator 62 · Denominator 76 |
| Transfer of health information to patient | 91.42% |
96.28%
4.9 pts worse
|
Numerator 213 · Denominator 233 |
| Resident COVID-19 vaccinations up to date | 36.77% |
25.2%
11.6 pts better
|
Numerator 57 · Denominator 155 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.3%
6.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
11.8%
2 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 9.2% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
0.9%
0.4 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 1.6% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.6% |
91.0%
1.4 pts worse
|
79.7%
9.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.2% |
17.4%
10.8 pts worse
|
23.9%
4.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.2% · Observed 24.0% · Expected 20.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-30 · Fire 2023-08-30
2 health deficiencies
Top issue: Infection Control (1 deficiency)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2021-12-29 · Fire 2021-12-29
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 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
2025-05-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-07-13
F · Potential for more than minimal harm
2025-05-15
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-07-13
D · Potential for more than minimal harm
2025-05-15
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-07-13
D · Potential for more than minimal harm
2025-05-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-13
D · Potential for more than minimal harm
2025-05-15
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 2025-07-13
D · Potential for more than minimal harm
2025-05-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-13
D · Potential for more than minimal harm
2025-05-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-13
D · Potential for more than minimal harm
2025-05-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-13
D · Potential for more than minimal harm
2025-05-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-30
D · Potential for more than minimal harm
2023-08-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-08-30
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 2023-10-25
D · Potential for more than minimal harm
2023-08-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-08-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-08-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-08-30
K906 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas cylinders are properly stored.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-08-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-08-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-25
F · Potential for more than minimal harm
2021-12-29
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 2022-02-25
D · Potential for more than minimal harm
2021-12-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-02-25
D · Potential for more than minimal harm
2021-12-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-02-25
Inspection history
Recent health citations
G · Actual harm
2025-12-01
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 2025-12-20
G · Actual harm
2025-12-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-20
E · Potential for more than minimal harm
2025-05-15
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 2025-07-14
D · Potential for more than minimal harm
2025-05-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-05-15
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 2025-07-14
D · Potential for more than minimal harm
2025-05-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-14
B · Minimal harm
2025-05-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-14
E · Potential for more than minimal harm
2023-08-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-15
D · Potential for more than minimal harm
2023-08-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-10-15
D · Potential for more than minimal harm
2021-12-29
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2022-02-08
D · Potential for more than minimal harm
2021-12-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-02-08
Penalties and ownership
What sits behind the stars
Ownership
Western States Lodging
5% Or Greater Direct Ownership Interest · Organization
Taylors Tcu
5% Or Greater Direct Ownership Interest · Organization
Dearden, Lance
Operational/Managerial Control · Individual
Exmar Company, LLC
5% Or Greater Indirect Ownership Interest · Organization
Fairholm Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Fairholm, Corey
5% Or Greater Indirect Ownership Interest · Individual
Fairholm, Paul
5% Or Greater Indirect Ownership Interest · Individual
Griffiths, Gary
5% Or Greater Indirect Ownership Interest · Individual
Hampton, Mark
5% Or Greater Indirect Ownership Interest · Individual
Miles, Richard
5% Or Greater Indirect Ownership Interest · Individual
Miles, Stephen
5% Or Greater Indirect Ownership Interest · Individual
Stubbs, Rachael
Operational/Managerial Control · Individual
The Miles Group
5% Or Greater Indirect Ownership Interest · Organization
Webster, David
5% Or Greater Indirect Ownership Interest · Individual
Western Lodging & Development, LLC
5% Or Greater Indirect Ownership Interest · Organization
Western States Lodging
Operational/Managerial Control · Organization
White, Richard
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Monument Healthcare Taylorsville
Salt Lake City, UT
4-star overall rating with 3-star inspections with $7,525 in total fines with 8 recent health deficiencies
#2
Rocky Mountain Care - Hunter Hollow
West Valley City, UT
2-star overall rating with 1-star inspections with $20,318 in total fines with 7 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Cascades at Riverwalk
Midvale, UT
4-star overall rating with 3-star inspections with $23,829 in total fines with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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