Cycle 1
Health 2023-11-16 · Fire 2023-11-16
13 health deficiencies
Top issue: Administration (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
North Logan, UT
Maple Springs Senior Living
1-star overall rating with 2-star inspections with 13 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
350 East 2200 North, North Logan, UT
(435) 753-9400
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
36
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Maple Springs Living
Operator or chain grouping
Approved since
2017-04-14
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
3 facilities
Chain averages 3 overall / 2 health / 4 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
0.78
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
3.58
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
5.05
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.47
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.58
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.26
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
0.74
CMS adjusted RN staffing hours
Adjusted total hours
4.80
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
940
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.92
Composite VBP score used to determine payment impact.
Payment multiplier
1.0169
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.17
Baseline 16.21% · Performance 17.64% · Measure score 8.17 · Achievement 8.17 · Improvement 0
Healthcare-associated infections
6.18
Baseline 5.18% · Performance 5.99% · Measure score 6.18 · Achievement 6.18 · Improvement 0
Total nurse turnover
1.72
Baseline 63.27% · Performance 56.67% · Measure score 1.72 · Achievement 1.72 · Improvement 1.22
Adjusted total nurse staffing
8.70
Baseline 4.44 hours · Performance 5.55 hours · Measure score 8.70 · Achievement 8.70 · Improvement 7.80
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.11% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 253 · Observed rate 6.32% · Lower 95% interval 6.48% |
| Discharge to community | 65.52% |
50.57%
14.9 pts better
|
Better than the National Rate · Eligible stays 242 · Observed rate 70.25% · Lower 95% interval 60.8% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 136 · Denominator 136 |
| Falls with major injury | 2.21% |
0.77%
1.4 pts worse
|
Numerator 3 · Denominator 136 |
| Discharge self-care score | 31.43% |
53.69%
22.3 pts worse
|
Numerator 33 · Denominator 105 |
| Discharge mobility score | 65.71% |
50.94%
14.8 pts better
|
Numerator 69 · Denominator 105 |
| Pressure ulcers or injuries, new or worsened | 1.47% |
2.29%
0.8 pts better
|
Numerator 2 · Denominator 136 · Adjusted rate 2.17% |
| Healthcare-associated infections requiring hospitalization | 5.99% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 146 · Observed rate 3.42% · Lower 95% interval 3.55% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 40.94% |
42%
1.1 pts worse
|
Numerator 52 · Denominator 127 |
| Discharge function score | 37.14% |
56.45%
19.3 pts worse
|
Numerator 39 · Denominator 105 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 115 · Denominator 115 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 38.24% |
25.2%
13 pts better
|
Numerator 26 · Denominator 68 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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% · 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 | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.5% |
16.1%
8.6 pts better
|
11.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · 4Q avg 7.5% |
| Percentage of long-stay residents who lose too much weight | 11.3% |
3.8%
7.5 pts worse
|
5.4%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.2% |
24.1%
10.9 pts better
|
19.6%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.7% |
15.4%
1.3 pts worse
|
16.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.7% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.9% |
13.6%
4.7 pts better
|
14.9%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.9% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.8%
1.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.9% |
22.4%
10.5 pts worse
|
19.8%
13.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 32.9% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
4.1%
0.1 pts worse
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.9% |
93.3%
0.4 pts worse
|
81.7%
11.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.9% · Q2 91.3% · Q3 97.1% · Q4 98.7% · 4Q avg 92.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.1% |
11.8%
0.7 pts better
|
12.0%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.1% · Observed 12.0% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
0.9%
2 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.8% · Q3 3.7% · Q4 3.4% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.3% |
91.0%
0.7 pts worse
|
79.7%
10.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
17.4%
6.9 pts worse
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 25.0% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-01-13 · Fire 2022-01-13
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2019-09-26 · Fire 2019-09-26
16 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-11-16
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-11-30
F · Potential for more than minimal harm
2023-11-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-12-31
F · Potential for more than minimal harm
2023-11-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-12-07
F · Potential for more than minimal harm
2023-11-16
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 2023-11-20
D · Potential for more than minimal harm
2023-11-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-11-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-20
D · Potential for more than minimal harm
2022-01-13
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 2022-01-20
E · Potential for more than minimal harm
2019-09-26
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 2019-09-25
E · Potential for more than minimal harm
2019-09-26
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-09-26
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 2019-09-25
D · Potential for more than minimal harm
2019-09-26
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-09-25
D · Potential for more than minimal harm
2019-09-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-09-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-09-25
D · Potential for more than minimal harm
2019-09-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-09-25
Inspection history
Recent health citations
G · Actual harm
2025-12-08
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Not marked corrected
E · Potential for more than minimal harm
2023-11-16
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 2023-12-20
E · Potential for more than minimal harm
2023-11-16
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 2023-12-23
D · Potential for more than minimal harm
2023-11-16
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 2023-12-25
D · Potential for more than minimal harm
2023-11-16
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 2023-12-20
D · Potential for more than minimal harm
2023-11-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-16
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 2023-12-20
D · Potential for more than minimal harm
2023-11-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-16
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 2023-12-31
D · Potential for more than minimal harm
2023-11-16
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-16
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2023-12-31
D · Potential for more than minimal harm
2023-11-16
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 2023-12-22
D · Potential for more than minimal harm
2023-11-16
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-12-20
F · Potential for more than minimal harm
2022-01-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-10
E · Potential for more than minimal harm
2022-01-13
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 2022-02-10
E · Potential for more than minimal harm
2022-01-13
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-02-10
D · Potential for more than minimal harm
2022-01-13
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2022-02-10
E · Potential for more than minimal harm
2019-09-26
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 2019-12-01
E · Potential for more than minimal harm
2019-09-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-12-01
E · Potential for more than minimal harm
2019-09-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-12-01
E · Potential for more than minimal harm
2019-09-26
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 2019-12-01
E · Potential for more than minimal harm
2019-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-12-01
E · Potential for more than minimal harm
2019-09-26
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2019-12-01
D · Potential for more than minimal harm
2019-09-26
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 2019-12-01
D · Potential for more than minimal harm
2019-09-26
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2019-12-01
D · Potential for more than minimal harm
2019-09-26
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2019-12-01
D · Potential for more than minimal harm
2019-09-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-12-01
D · Potential for more than minimal harm
2019-09-26
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 2019-12-01
D · Potential for more than minimal harm
2019-09-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-12-01
D · Potential for more than minimal harm
2019-09-26
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 2019-12-01
D · Potential for more than minimal harm
2019-09-26
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2019-12-01
D · Potential for more than minimal harm
2019-09-26
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2019-12-01
D · Potential for more than minimal harm
2019-09-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2019-12-01
Penalties and ownership
What sits behind the stars
Ownership
Dunn, Marc
5% Or Greater Direct Ownership Interest · Individual
Larsen, Gregory
5% Or Greater Direct Ownership Interest · Individual
Larsen, Nicholas
5% Or Greater Direct Ownership Interest · Individual
Dunn, Marc
Corporate Director · Individual
Larsen, Gregory
Corporate Director · Individual
Larsen, Nicholas
Operational/Managerial Control · Individual
Larsen, Nicholas
Corporate Director · Individual
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#2
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#3
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4-star overall rating with 3-star inspections with 5 recent health deficiencies
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