Cycle 1
Health 2024-05-23 · Fire 2024-05-23
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Taylorsville, UT
Meadow Peak Rehabilitation
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
6084 South Summit Vista Boulevard, Taylorsville, UT
(385) 255-1105
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
75
Certified beds
Average residents
71
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Monument Health Group
Operator or chain grouping
Approved since
2021-04-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
Yes
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
1.16
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.30
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.88
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
3.54
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.95
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.05
CMS adjusted RN staffing hours
Adjusted total hours
3.51
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
26%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,084
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.08
Composite VBP score used to determine payment impact.
Payment multiplier
1.0153
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 17.80% · Performance 16.60% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
10
Baseline 4.49% · Performance 4.62% · Measure score 10 · Achievement 10 · Improvement 0
Total nurse turnover
1.19
Baseline 63.93% · Performance 58.82% · Measure score 1.19 · Achievement 1.19 · Improvement 0.81
Adjusted total nurse staffing
2.85
Baseline 4.31 hours · Performance 3.89 hours · Measure score 2.85 · Achievement 2.85 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.01% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 250 · Observed rate 8.4% · Lower 95% interval 7.2% |
| Discharge to community | 67.4% |
50.57%
16.8 pts better
|
Better than the National Rate · Eligible stays 211 · Observed rate 66.82% · Lower 95% interval 61.08% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 70.47% |
95.27%
24.8 pts worse
|
Numerator 136 · Denominator 193 |
| Falls with major injury | 0.52% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 193 |
| Discharge self-care score | 43.66% |
53.69%
10 pts worse
|
Numerator 62 · Denominator 142 |
| Discharge mobility score | 43.66% |
50.94%
7.3 pts worse
|
Numerator 62 · Denominator 142 |
| Pressure ulcers or injuries, new or worsened | 7.25% |
2.29%
5 pts worse
|
Numerator 14 · Denominator 193 · Adjusted rate 7.36% |
| Healthcare-associated infections requiring hospitalization | 4.62% |
7.12%
2.5 pts better
|
No Different than the National Rate · Eligible stays 176 · Observed rate 1.7% · Lower 95% interval 2.67% |
| Staff COVID-19 vaccination coverage | 11.98% |
8.2%
3.8 pts better
|
Numerator 20 · Denominator 167 |
| Staff flu vaccination coverage | 33.56% |
42%
8.4 pts worse
|
Numerator 50 · Denominator 149 |
| Discharge function score | 34.51% |
56.45%
21.9 pts worse
|
Numerator 49 · Denominator 142 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 150 · Denominator 150 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 32.74% |
25.2%
7.5 pts better
|
Numerator 37 · Denominator 113 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.2
0.7 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
96.8%
2.6 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
98.0%
0.2 pts worse
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
2.6%
0.3 pts worse
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.8% · Q3 2.2% · Q4 2.3% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
16.1%
12.3 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.0% · Q3 2.3% · Q4 2.8% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
3.8%
2 pts worse
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 10.3% · Q3 2.4% · Q4 2.5% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.3% |
24.1%
8.2 pts worse
|
19.6%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.6% · Q2 27.5% · Q3 32.6% · Q4 37.5% · 4Q avg 32.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.3% |
15.4%
11.1 pts better
|
16.7%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.4% · Q3 3.2% · Q4 6.7% · 4Q avg 4.3% · 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 | 3.0% |
18.3%
15.3 pts better
|
16.3%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.7% |
13.6%
10.9 pts better
|
14.9%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.9% · Q3 4.9% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
0.9%
1.2 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.2% · Q3 2.5% · Q4 1.7% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
1.8%
About the same
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 2.2% · Q4 2.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.9% |
22.4%
0.5 pts worse
|
19.8%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.5% · Q2 34.2% · Q3 9.9% · Q4 21.0% · 4Q avg 22.9% |
| Percentage of long-stay residents with pressure ulcers | 9.9% |
4.1%
5.8 pts worse
|
5.1%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 16.0% · Q3 14.0% · Q4 3.9% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.8% |
93.3%
5.5 pts worse
|
81.7%
6.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 80.5% · Q2 87.4% · Q3 90.6% · Q4 93.3% · 4Q avg 87.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
11.8%
5.8 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 5.7% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
0.9%
0.3 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 1.1% · Q3 0.6% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.5% |
91.0%
11.5 pts worse
|
79.7%
0.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.8% |
17.4%
2.4 pts worse
|
23.9%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 19.0% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-27 · Fire 2022-10-27
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-04-28 · Fire 2021-04-28
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-22
F · Potential for more than minimal harm
2024-05-23
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-05-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-05-23
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-05-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-05-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-05-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-23
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-05-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-28
D · Potential for more than minimal harm
2024-05-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-22
E · Potential for more than minimal harm
2022-10-27
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-10-27
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-10-27
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 2022-12-16
D · Potential for more than minimal harm
2022-10-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-10-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-12-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-15
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 2025-08-31
G · Actual harm
2024-05-23
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 2024-06-10
D · Potential for more than minimal harm
2024-05-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-05-23
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 2024-06-10
D · Potential for more than minimal harm
2024-05-23
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-06-10
G · Actual harm
2022-10-27
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 2022-12-12
E · Potential for more than minimal harm
2022-10-27
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 2022-12-12
D · Potential for more than minimal harm
2022-10-27
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-12-12
D · Potential for more than minimal harm
2022-10-27
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 2022-12-12
D · Potential for more than minimal harm
2022-10-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-12-12
D · Potential for more than minimal harm
2022-10-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-12-12
D · Potential for more than minimal harm
2022-10-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-12
D · Potential for more than minimal harm
2022-10-27
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 2022-12-12
Penalties and ownership
What sits behind the stars
Ownership
Bartholomew, Brenda
Corporate Officer · Individual
Hardman, Michelle
Operational/Managerial Control · Individual
Mission Health Services
Operational/Managerial Control · Organization
Murray, Brian
Corporate Officer · Individual
Wootton, Zachary
Operational/Managerial Control · Individual
Zimbelman, Michelle
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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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
#2
Legacy Village Rehabilitation
Taylorsville, UT
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Alpine Meadow Rehabilitation and Nursing
West Valley City, UT
3-star overall rating with 2-star inspections with $33,275 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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