12 health deficiencies
Top issue: Administration (3 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Salt Lake City, UT
1-star overall rating with 1-star inspections with abuse icon flag with $31,331 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
433 East 2700 South, Salt Lake City, UT
(801) 487-2248
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
41
Certified beds
Average residents
29
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Cascades Healthcare
Operator or chain grouping
Approved since
2004-05-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 2 overall / 2 health / 2 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
RN hours / resident day
1.38
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.17
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.21
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.76
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.93
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.50
CMS adjusted RN staffing hours
Adjusted total hours
4.10
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
71%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 70.59% · Performance 87.04% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.34 hours · Performance 3.01 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 62 |
| Staff flu vaccination coverage | 55.41% |
42%
13.4 pts better
|
Numerator 41 · Denominator 74 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
96.8%
2.3 pts worse
|
93.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.1% · Q2 100.0% · Q3 100.0% · Q4 81.5% · 4Q avg 94.5% |
| 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 | 4.7% |
2.6%
2.1 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.9% · Q3 6.1% · Q4 0.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 28.0% |
16.1%
11.9 pts worse
|
11.4%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 29.6% · Q3 26.9% · Q4 20.8% · 4Q avg 28.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
3.8%
3.8 pts better
|
5.4%
5.4 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 who received an antianxiety or hypnotic medication | 43.6% |
24.1%
19.5 pts worse
|
19.6%
24 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.7% · Q2 41.4% · Q3 41.4% · Q4 45.5% · 4Q avg 43.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.5% |
15.4%
3.1 pts worse
|
16.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.5% · 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 | 9.3% |
18.3%
9 pts better
|
16.3%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.8% |
13.6%
2.8 pts better
|
14.9%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 7.4% · Q3 7.4% · Q4 10.0% · 4Q avg 10.8% · 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 | 0.8% |
1.8%
1 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.0% |
22.4%
1.6 pts worse
|
19.8%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 21.8% · Q3 21.0% · Q4 21.8% · 4Q avg 24.0% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
4.1%
0.6 pts worse
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.9% · Q3 3.2% · Q4 3.9% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.8% |
93.3%
11.5 pts worse
|
81.7%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 74.1% · Q2 86.4% · Q4 85.0% · 4Q avg 81.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
0.9%
0.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.8% |
91.0%
9.2 pts worse
|
79.7%
2.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.8% |
Survey summary
Top issue: Administration (3 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Top issue: Quality of Life and Care (12 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-12-15
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-12-15
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-29
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-03-29
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-06
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-06-16
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-15
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 2025-12-15
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2025-12-15
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-12-15
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-12-15
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-15
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-05
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-12-15
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-12-15
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-12-15
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-12-15
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-12-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-09
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-19
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-04-19
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-04-19
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-04-19
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-04-19
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 2024-04-19
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-04-19
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-04-19
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-04-19
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 2024-04-19
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-19
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-04-19
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-19
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-19
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-04-19
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-04-19
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-04-19
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 2024-04-19
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 2024-04-19
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 2024-04-19
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-04-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-19
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-19
Health
Implement a program that monitors antibiotic use.
Corrected 2024-04-19
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2024-04-19
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-04-19
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-19
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-04-19
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-04-19
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-04-19
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-04-19
Health
Provide activities to meet all resident's needs.
Corrected 2024-04-19
Health
Provide appropriate foot care.
Corrected 2024-04-19
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-19
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-04-19
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-19
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-04-19
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-04-19
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-19
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-04-19
Health
Keep all essential equipment working safely.
Corrected 2024-04-19
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-04-19
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-07-15
Health
Respond appropriately to all alleged violations.
Corrected 2022-07-15
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-07-15
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-07-15
Penalties and ownership
Fine · fine $31,331
Fine
Payment Denial · denial start 2024-04-13 · 6 days
6 day denial
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Nearby options
Salt Lake City, UT
1-star overall rating with 1-star inspections with Special Focus status with $31,391 in total fines with 20 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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5-star overall rating with 5-star inspections with 5 recent health deficiencies
Salt Lake City, UT
3-star overall rating with 3-star inspections with 5 recent health deficiencies
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