Cycle 1
Health 2024-02-07 · Fire 2024-02-07
19 health deficiencies
Top issue: Administration (5 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Delta, UT
Millard County Care and Rehabilitation
3-star overall rating with 2-star inspections with $19,656 in total fines with 19 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
150 South White Sage Avenue, Delta, UT
(435) 864-2944
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
60
Certified beds
Average residents
51
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-05-20
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
0.84
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.31
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.55
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.14
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.51
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.64
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
0.96
CMS adjusted RN staffing hours
Adjusted total hours
4.08
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
95%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
92%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,876
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.15
Performance 19.05% · Measure score 5.15 · Achievement 5.15 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.82
Performance 6.69% · Measure score 3.82 · Achievement 3.82 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Performance 87.23% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.45
Baseline 3.56 hours · Performance 3.77 hours · Measure score 2.45 · Achievement 2.45 · Improvement 0.48
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.76% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 3.7% · Lower 95% interval 5.97% |
| Discharge to community | 55.5% |
50.57%
4.9 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 57.14% · Lower 95% interval 44.34% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 23 · Denominator 23 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 23 |
| Discharge self-care score | 47.83% |
53.69%
5.9 pts worse
|
Numerator 11 · Denominator 23 |
| Discharge mobility score | 69.57% |
50.94%
18.6 pts better
|
Numerator 16 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 23 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.69% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 3.03% · Lower 95% interval 3.55% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 58 |
| Staff flu vaccination coverage | 43.82% |
42%
1.8 pts better
|
Numerator 39 · Denominator 89 |
| Discharge function score | 60.87% |
56.45%
4.4 pts better
|
Numerator 14 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · 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 | 0.3 |
1.2
0.9 pts better
|
1.9
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.4 · 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 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
96.8%
1.5 pts worse
|
93.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 95.8% · Q3 93.9% · Q4 95.7% · 4Q avg 95.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.0% |
98.0%
4 pts worse
|
95.5%
1.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
2.6%
2.6 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 4.2% · Q3 6.1% · Q4 4.3% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
16.1%
13.9 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 4.3% · Q4 2.2% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 14.4% |
3.8%
10.6 pts worse
|
5.4%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 17.0% · Q3 10.4% · Q4 10.6% · 4Q avg 14.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 49.2% |
24.1%
25.1 pts worse
|
19.6%
29.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 51.1% · Q2 47.9% · Q3 49.0% · Q4 48.9% · 4Q avg 49.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.7% |
15.4%
16.3 pts worse
|
16.7%
15 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 30.2% · Q3 34.1% · Q4 34.2% · 4Q avg 31.7% · 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 | 11.4% |
18.3%
6.9 pts better
|
16.3%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 13.7% · Q3 14.5% · Q4 7.4% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.4% |
13.6%
0.8 pts worse
|
14.9%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 14.9% · Q3 22.4% · Q4 8.7% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.5% |
0.9%
3.6 pts worse
|
1.0%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.9% · Q3 5.0% · Q4 4.4% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.8%
0.7 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.2% |
22.4%
12.8 pts worse
|
19.8%
15.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.4% · Q2 33.2% · Q3 23.2% · Q4 48.7% · 4Q avg 35.2% |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
4.1%
3.6 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 12.1% · Q3 4.4% · Q4 6.9% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.2% |
93.3%
8.1 pts worse
|
81.7%
3.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q4 75.0% · 4Q avg 85.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
11.8%
11.8 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 10.1% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
17.4%
3.4 pts worse
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 19.0% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-05 · Fire 2022-05-05
8 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2019-12-05 · Fire 2019-12-05
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
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
2024-02-07
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-04-05
D · Potential for more than minimal harm
2022-05-05
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-06-28
Inspection history
Recent health citations
G · Actual harm
2024-02-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-24
F · Potential for more than minimal harm
2024-02-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-24
F · Potential for more than minimal harm
2024-02-07
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2024-03-24
E · Potential for more than minimal harm
2024-02-07
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-03-24
E · Potential for more than minimal harm
2024-02-07
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 2024-03-24
E · Potential for more than minimal harm
2024-02-07
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 2024-03-24
D · Potential for more than minimal harm
2024-02-07
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 2024-03-24
D · Potential for more than minimal harm
2024-02-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-24
D · Potential for more than minimal harm
2024-02-07
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 2024-03-24
D · Potential for more than minimal harm
2024-02-07
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 2024-03-24
D · Potential for more than minimal harm
2024-02-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-24
D · Potential for more than minimal harm
2024-02-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-03-24
D · Potential for more than minimal harm
2024-02-07
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-03-24
D · Potential for more than minimal harm
2024-02-07
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2024-03-24
D · Potential for more than minimal harm
2024-02-07
F779 · Administration Deficiencies
Health
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
Corrected 2024-03-24
D · Potential for more than minimal harm
2024-02-07
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-03-24
D · Potential for more than minimal harm
2024-02-07
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-03-24
D · Potential for more than minimal harm
2024-02-07
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2024-03-24
D · Potential for more than minimal harm
2024-02-07
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-03-24
E · Potential for more than minimal harm
2022-05-05
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 2022-06-17
E · Potential for more than minimal harm
2022-05-05
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 2022-06-17
E · Potential for more than minimal harm
2022-05-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-05-05
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-05
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-05
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 2022-06-17
D · Potential for more than minimal harm
2022-05-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-17
D · Potential for more than minimal harm
2022-05-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-06-17
G · Actual harm
2019-12-05
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 2020-03-02
E · Potential for more than minimal harm
2019-12-05
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 2020-03-02
E · Potential for more than minimal harm
2019-12-05
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 2020-01-31
D · Potential for more than minimal harm
2019-12-05
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 2020-01-31
Penalties and ownership
What sits behind the stars
$19,656
2024-02-07
Fine
Fine · fine $19,656
Fine
Ownership
Christensen, Jeffery
5% Or Greater Indirect Ownership Interest · Individual
Christensen, Jeffery
Operational/Managerial Control · Individual
Christensen, Jeffery
Contracted Managing Employee · Individual
Christensen, Jeffery
W-2 Managing Employee · Individual
Dearden, Tony
Corporate Director · Individual
Jackson, Lon
Corporate Director · Individual
Millard County Care & Rehabilitation Inc
Operational/Managerial Control · Organization
Standworth, Rex
Corporate Director · Individual
Traditions Health Care, Inc.
Operational/Managerial Control · Organization
Walker, Kathy
Corporate Director · Individual
Nearby options
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Mission at Community Living Rehabilitation Center
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#2
Mission at Nephi Nursing and Rehabilitation
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4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Monument Healthcare Richfield (Mission at Richfiel
Richfield, UT
5-star overall rating with 4-star inspections with $8,148 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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