Cycle 1
Health 2025-04-30 · Fire 2025-04-30
21 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Salt Lake City, UT
Midtown Manor
3-star overall rating with 2-star inspections with 21 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
125 South 900 West, Salt Lake City, UT
(801) 363-6340
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
70
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-10-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.92
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.27
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.76
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.95
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.16
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
3.07
CMS adjusted total nurse staffing hours
Case-mix index
1.76
Higher values indicate more complex resident acuity
RN turnover
8%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,366
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.26
Composite VBP score used to determine payment impact.
Payment multiplier
0.9932
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
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
8.05
Performance 30.77% · Measure score 8.05 · Achievement 8.05 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.19 hours · Performance 2.85 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 7 · 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 1 · 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 Not Available · Newly certified or not enough cases to report. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · Newly certified or not enough cases to report. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 64.44% |
8.2%
56.2 pts better
|
Numerator 58 · Denominator 90 |
| Staff flu vaccination coverage | 97.94% |
42%
55.9 pts better
|
Numerator 95 · Denominator 97 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| 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 Not Available · Newly certified or not enough cases to report. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.5
1.3 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.3 · Expected 2.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
96.8%
0.6 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.0% · Q3 95.0% · Q4 97.4% · 4Q avg 97.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
98.0%
0.7 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| 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% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 86.0% |
16.1%
69.9 pts worse
|
11.4%
74.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.6% · Q2 85.9% · Q3 87.2% · Q4 87.0% · 4Q avg 86.0% |
| Percentage of long-stay residents who lose too much weight | 16.3% |
3.8%
12.5 pts worse
|
5.4%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 17.4% · Q3 14.7% · Q4 16.4% · 4Q avg 16.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.0% |
24.1%
9.1 pts better
|
19.6%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 13.9% · Q3 10.5% · Q4 18.4% · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 57.6% |
15.4%
42.2 pts worse
|
16.7%
40.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 65.5% · Q4 63.3% · 4Q avg 57.6% · 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 | 15.3% |
18.3%
3 pts better
|
16.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 9.9% · Q4 19.4% · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.8% |
13.6%
4.2 pts worse
|
14.9%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 7.4% · Q3 19.2% · Q4 27.0% · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.6% |
0.9%
5.7 pts worse
|
1.0%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 5.2% · Q3 10.1% · Q4 9.6% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.8%
0.6 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 0.0% · Q4 1.4% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.2% |
22.4%
20.2 pts better
|
19.8%
17.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 0.0% · Q3 3.5% · Q4 0.0% · 4Q avg 2.2% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
4.1%
1.6 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.6% · Q3 2.3% · Q4 2.5% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 65.5% |
93.3%
27.8 pts worse
|
81.7%
16.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 65.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-30 · Fire 2023-08-30
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-10-28 · Fire 2021-10-28
13 health deficiencies
Top issue: Resident Assessment and Care Planning (4 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
2025-04-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-29
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-04-30
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-04-30
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-04-30
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 2025-06-30
E · Potential for more than minimal harm
2025-04-30
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-04-30
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 2025-06-30
D · Potential for more than minimal harm
2025-04-30
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-04-30
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-04-30
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 2025-06-30
D · Potential for more than minimal harm
2025-04-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-04-30
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 2025-06-30
D · Potential for more than minimal harm
2025-04-30
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-04-30
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 2025-06-30
D · Potential for more than minimal harm
2025-04-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-04-30
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 2025-06-30
D · Potential for more than minimal harm
2025-04-30
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-04-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-04-30
F728 · Nursing and Physician Services Deficiencies
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 2025-06-30
D · Potential for more than minimal harm
2025-04-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-04-30
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-04-30
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 2025-06-30
F · Potential for more than minimal harm
2023-08-30
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 2023-10-25
F · Potential for more than minimal harm
2023-08-30
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-08-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-08-30
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-08-30
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 2023-10-25
D · Potential for more than minimal harm
2023-08-30
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 2023-10-25
D · Potential for more than minimal harm
2023-08-30
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 2023-10-25
F · Potential for more than minimal harm
2021-10-28
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 2022-01-15
E · Potential for more than minimal harm
2021-10-28
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 2022-01-15
E · Potential for more than minimal harm
2021-10-28
F584 · Resident Rights Deficiencies
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 2022-01-15
D · Potential for more than minimal harm
2021-10-28
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-01-15
D · Potential for more than minimal harm
2021-10-28
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 2022-01-15
D · Potential for more than minimal harm
2021-10-28
F657 · Resident Assessment and Care Planning Deficiencies
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 2022-01-15
D · Potential for more than minimal harm
2021-10-28
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 2022-01-15
D · Potential for more than minimal harm
2021-10-28
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-01-15
D · Potential for more than minimal harm
2021-10-28
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2022-01-15
D · Potential for more than minimal harm
2021-10-28
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 2022-01-15
D · Potential for more than minimal harm
2021-10-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-15
D · Potential for more than minimal harm
2021-10-28
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2022-01-15
C · Minimal harm
2021-10-28
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-01-15
Penalties and ownership
What sits behind the stars
Ownership
Adams & Adams Enterprises Inc
Operational/Managerial Control · Organization
Adams, Robert
Operational/Managerial Control · Individual
Barton, Michelle
Corporate Officer · Individual
Nearby options
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#3
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