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
Staffing
Hours and turnover
RN hours / resident day
0.78
Registered nurse staffing
LPN hours / resident day
0.69
Licensed practical nurse staffing
Aide hours / resident day
3.58
Nurse aide staffing
Weekend hours
4.58
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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