Cycle 1
Health 2025-06-25 · Fire 2025-06-25
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Centerfield, UT
Mission at Community Living Rehabilitation Center
3-star overall rating with 3-star inspections with $6,351 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
10 West 400 South, Centerfield, UT
(435) 528-2800
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
46
Certified beds
Average residents
40
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Mission Health Services
Operator or chain grouping
Approved since
2010-12-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 3 overall / 3 health / 3 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
0.74
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.46
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
1.73
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
2.92
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.52
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
3.12
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
14%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,498
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.38
Baseline 18.81% · Performance 20.33% · Measure score 2.38 · Achievement 2.38 · Improvement 0
Healthcare-associated infections
2.44
Baseline 5.53% · Performance 7.11% · Measure score 2.44 · Achievement 2.44 · Improvement 0
Total nurse turnover
1.72
Baseline 52.94% · Performance 56.67% · Measure score 1.72 · Achievement 1.72 · Improvement 0
Adjusted total nurse staffing
0.10
Baseline 2.82 hours · Performance 3 hours · Measure score 0.10 · Achievement 0 · Improvement 0.10
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.97% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 59 · Observed rate 5.08% · Lower 95% interval 5.88% |
| Discharge to community | 48.23% |
50.57%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 48.15% · Lower 95% interval 35.28% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.92% |
95.27%
2.7 pts better
|
Numerator 47 · Denominator 48 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 48 |
| Discharge self-care score | 30.56% |
53.69%
23.1 pts worse
|
Numerator 11 · Denominator 36 |
| Discharge mobility score | 30.56% |
50.94%
20.4 pts worse
|
Numerator 11 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 2.08% |
2.29%
0.2 pts better
|
Numerator 1 · Denominator 48 · Adjusted rate 2.15% |
| Healthcare-associated infections requiring hospitalization | 7.1% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 41 · Observed rate 4.88% · Lower 95% interval 3.29% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 75 |
| Staff flu vaccination coverage | 21.6% |
42%
20.4 pts worse
|
Numerator 27 · Denominator 125 |
| Discharge function score | 30.56% |
56.45%
25.9 pts worse
|
Numerator 11 · Denominator 36 |
| 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 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.04% |
25.2%
12.2 pts worse
|
Numerator 3 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.2
0.8 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.1 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
1.5
1 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.0% |
96.8%
3.8 pts worse
|
93.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 78.1% · Q2 100.0% · Q3 96.7% · Q4 97.2% · 4Q avg 93.0% |
| 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 | 2.3% |
2.6%
0.3 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 6.5% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.8% |
16.1%
7.3 pts better
|
11.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 4.3% · Q3 3.4% · Q4 16.7% · 4Q avg 8.8% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
3.8%
2.5 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 7.4% · Q3 0.0% · Q4 3.3% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.6% |
24.1%
4.5 pts worse
|
19.6%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.7% · Q2 28.6% · Q3 23.1% · Q4 26.7% · 4Q avg 28.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.1% |
15.4%
6.7 pts worse
|
16.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 23.8% · 4Q avg 22.1% · 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 | 9.1% |
18.3%
9.2 pts better
|
16.3%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 4.5% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.0% |
13.6%
2.4 pts worse
|
14.9%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 22.2% · Q3 16.0% · Q4 3.4% · 4Q avg 16.0% · 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 0.0% · Q3 3.3% · 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 | 27.2% |
22.4%
4.8 pts worse
|
19.8%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 16.3% · Q3 26.1% · Q4 34.0% · 4Q avg 27.2% |
| Percentage of long-stay residents with pressure ulcers | 9.2% |
4.1%
5.1 pts worse
|
5.1%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 13.8% · Q3 11.8% · Q4 7.8% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.0% |
93.3%
12.3 pts worse
|
81.7%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 52.6% · Q2 76.6% · Q3 94.1% · Q4 97.4% · 4Q avg 81.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.3% |
11.8%
0.5 pts worse
|
12.0%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 11.4% · Expected 10.4% · 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 · Q1 0.0% · Q2 0.0% · 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 | 83.3% |
91.0%
7.7 pts worse
|
79.7%
3.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.6% |
17.4%
0.2 pts worse
|
23.9%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 14.3% · Expected 19.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-12 · Fire 2023-09-12
9 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-02-24 · Fire 2022-02-24
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-06-25
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 2025-07-14
D · Potential for more than minimal harm
2025-06-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-26
D · Potential for more than minimal harm
2023-09-12
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 2023-11-10
D · Potential for more than minimal harm
2023-09-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-09-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-10
D · Potential for more than minimal harm
2022-02-24
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 2022-04-14
D · Potential for more than minimal harm
2022-02-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-04-15
D · Potential for more than minimal harm
2022-02-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-04-14
D · Potential for more than minimal harm
2022-02-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-04-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-25
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 2025-08-15
E · Potential for more than minimal harm
2025-06-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-06-25
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 2025-08-15
D · Potential for more than minimal harm
2025-06-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-06-25
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-06-25
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 2025-08-15
D · Potential for more than minimal harm
2025-06-25
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-08-15
F · Potential for more than minimal harm
2023-09-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-09-12
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 2023-11-10
E · Potential for more than minimal harm
2023-09-12
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-09-12
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-09-12
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 2023-11-10
D · Potential for more than minimal harm
2023-09-12
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 2023-11-10
D · Potential for more than minimal harm
2023-09-12
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-09-12
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 2023-11-10
D · Potential for more than minimal harm
2023-09-12
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 2023-11-10
E · Potential for more than minimal harm
2022-02-24
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 2022-03-30
D · Potential for more than minimal harm
2022-02-24
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 2022-03-30
D · Potential for more than minimal harm
2022-02-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-03-30
D · Potential for more than minimal harm
2022-02-24
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 2022-03-30
Penalties and ownership
What sits behind the stars
$6,351
2023-07-31
Fine
Fine · fine $6,351
Fine
Ownership
Gunnison Valley Hospital
5% Or Greater Direct Ownership Interest · Organization
Bartholomew, Brenda
Corporate Officer · Individual
Blackham, Brady
Operational/Managerial Control · Individual
Mission Health Services
Operational/Managerial Control · Organization
Murray, Brian
Corporate Officer · Individual
Piquet, Shaeleen
Operational/Managerial Control · Individual
Squire, Nikelle
Operational/Managerial Control · Individual
Wootton, Zachary
Operational/Managerial Control · Individual
Zimbelman, Michelle
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
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
#2
Stonehenge of Richfield
Richfield, UT
5-star overall rating with 3-star inspections with 8 recent health deficiencies
#3
San Rafael Health and Rehabilitation
Ferron, UT
1-star overall rating with 1-star inspections with abuse icon flag with $29,347 in total fines with 14 recent health deficiencies
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