Cycle 1
Health 2024-03-28 · Fire 2024-03-28
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Payson, UT
Mervyn Sharp Bennion Central Utah Veterans Home
5-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1551 North Main Street, Payson, UT
(801) 465-5400
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
103
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avalon Health Care
Operator or chain grouping
Approved since
2013-10-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 4 overall / 3 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
1.85
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.38
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
3.40
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
5.63
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
2.24
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
5.16
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
1.45
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
2.35
CMS adjusted RN staffing hours
Adjusted total hours
7.14
CMS adjusted total nurse staffing hours
Case-mix index
1.08
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,173
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.26
Composite VBP score used to determine payment impact.
Payment multiplier
1.0056
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.35
Performance 20.34% · Measure score 2.35 · Achievement 2.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.09
Baseline 7.25% · Performance 7.21% · Measure score 2.09 · Achievement 2.09 · Improvement 0
Total nurse turnover
6.06
Performance 38.92% · Measure score 6.06 · Achievement 6.06 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
10
Baseline 5.89 hours · Performance 6.08 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.12% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 6.25% · Lower 95% interval 5.91% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.32 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 3.23% |
0.77%
2.5 pts worse
|
Numerator 1 · Denominator 31 |
| Discharge self-care score | 88.89% |
53.69%
35.2 pts better
|
Numerator 24 · Denominator 27 |
| Discharge mobility score | 77.78% |
50.94%
26.8 pts better
|
Numerator 21 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.21% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 6.45% · Lower 95% interval 3.06% |
| Staff COVID-19 vaccination coverage | 3.69% |
8.2%
4.5 pts worse
|
Numerator 9 · Denominator 244 |
| Staff flu vaccination coverage | 62.12% |
42%
20.1 pts better
|
Numerator 164 · Denominator 264 |
| Discharge function score | 85.19% |
56.45%
28.7 pts better
|
Numerator 23 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.2
0.3 pts worse
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
96.8%
2.1 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 97.9% · Q3 98.9% · Q4 100.0% · 4Q avg 98.9% |
| 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 | 3.7% |
2.6%
1.1 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.0% · Q3 5.4% · Q4 6.5% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 22.7% |
16.1%
6.6 pts worse
|
11.4%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 27.6% · Q3 23.3% · Q4 19.1% · 4Q avg 22.7% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
3.8%
0.4 pts worse
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 7.8% · Q3 0.0% · Q4 5.1% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.9% |
24.1%
9.2 pts better
|
19.6%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 12.8% · Q3 16.5% · Q4 16.5% · 4Q avg 14.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.5% |
15.4%
11.9 pts better
|
16.7%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 2.8% · Q3 2.9% · Q4 2.7% · 4Q avg 3.5% · 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 | 11.1% |
18.3%
7.2 pts better
|
16.3%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 17.1% · Q3 12.8% · Q4 8.1% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.2% |
13.6%
2.4 pts better
|
14.9%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 10.4% · Q3 12.8% · Q4 10.3% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.0% |
1.8%
2.2 pts worse
|
1.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 5.3% · Q3 4.3% · Q4 1.1% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.3% |
22.4%
4.1 pts better
|
19.8%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 21.6% · Q3 18.0% · Q4 15.0% · 4Q avg 18.3% |
| Percentage of long-stay residents with pressure ulcers | 1.4% |
4.1%
2.7 pts better
|
5.1%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 1.0% · Q4 2.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
93.3%
2.7 pts better
|
81.7%
14.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 100.0% · Q3 94.0% · Q4 93.9% · 4Q avg 96.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.9% |
11.8%
1.1 pts worse
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 11.5% · Expected 10.0% · Used in QM five-star |
| 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 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.0%
9 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.3% |
17.4%
3.1 pts better
|
23.9%
9.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 11.5% · Expected 19.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-04-07 · Fire 2022-04-07
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2019-10-10 · Fire 2019-10-10
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-03-28
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-26
E · Potential for more than minimal harm
2022-04-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-05-02
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-03-28
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 2024-04-19
D · Potential for more than minimal harm
2024-03-28
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 2024-04-19
D · Potential for more than minimal harm
2024-03-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-04-19
D · Potential for more than minimal harm
2024-03-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-19
G · Actual harm
2022-04-07
F690 · Quality of Life and Care Deficiencies
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 2022-05-02
E · Potential for more than minimal harm
2022-04-07
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 2022-05-02
E · Potential for more than minimal harm
2022-04-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-02
D · Potential for more than minimal harm
2022-04-07
F578 · Resident Rights Deficiencies
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 2022-05-02
D · Potential for more than minimal harm
2022-04-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-05-02
D · Potential for more than minimal harm
2022-04-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-05-02
D · Potential for more than minimal harm
2022-04-07
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 2022-05-02
E · Potential for more than minimal harm
2019-10-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-30
D · Potential for more than minimal harm
2019-10-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-10-30
D · Potential for more than minimal harm
2019-10-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-10-30
D · Potential for more than minimal harm
2019-10-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-10-30
D · Potential for more than minimal harm
2019-10-10
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 2019-10-30
Penalties and ownership
What sits behind the stars
Ownership
Avalon Health Care Management, Inc.
Operational/Managerial Control · Organization
Avalon Health Care, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Avalon Holding, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Avalon Va Management LLC
5% Or Greater Direct Ownership Interest · Organization
Avalon Veterans Services, L.l.c.
5% Or Greater Direct Ownership Interest · Organization
Burton, Harold
Corporate Director · Individual
Cooke, Peter
Corporate Director · Individual
Dangerfield, David
Corporate Director · Individual
Franklin, Christie
Corporate Director · Individual
Hash, Alan
Corporate Officer · Individual
Kirton, Charles
5% Or Greater Indirect Ownership Interest · Individual
Kirton, Charles
Corporate Director · Individual
Kirton, Charles
Corporate Officer · Individual
Kirton, Hyrum
Corporate Director · Individual
Owens, Mary
Corporate Officer · Individual
Paquette, Sebastian
Corporate Director · Individual
Parsons, Weston
W-2 Managing Employee · Individual
Stuart, Anne
Corporate Director · Individual
Stuart, Anne
Corporate Officer · Individual
Swinton, Brian
Corporate Director · Individual
Tippets, Carl
Corporate Director · Individual
Woltil, Robert
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Rocky Mountain Care - Maple Dell
Payson, UT
1-star overall rating with 1-star inspections with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Advanced Health Care of Salem
Salem, UT
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Spanish Fork Rehabilitation and Nursing
Spanish Fork, UT
1-star overall rating with 2-star inspections with abuse icon flag with $7,443 in total fines with 3 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
Jump out