Cycle 1
Health 2025-05-29 · Fire 2025-05-29
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Nephi, UT
Mission at Nephi Nursing and Rehabilitation
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1100 North 400 East, Nephi, UT
(435) 623-1721
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
80
Certified beds
Average residents
34
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Monument Health Group
Operator or chain grouping
Approved since
1986-12-22
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
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
1.09
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.60
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.21
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.91
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.39
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.72
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.15
CMS adjusted RN staffing hours
Adjusted total hours
4.13
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
73%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,480
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.57% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.31
Baseline 6.47% · Performance 6.55% · Measure score 4.31 · Achievement 4.31 · Improvement 0
Total nurse turnover
0
Baseline 64.10% · Performance 63.83% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.51
Baseline 4.11 hours · Performance 3.22 hours · Measure score 0.51 · Achievement 0.51 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.69% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 38 · Observed rate 10.53% · Lower 95% interval 7.09% |
| Discharge to community | 43.32% |
50.57%
7.2 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 35.14% · Lower 95% interval 31.14% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 19 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | 6.55% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 3.45% · Lower 95% interval 3.29% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 61 |
| Staff flu vaccination coverage | 34.15% |
42%
7.9 pts worse
|
Numerator 28 · Denominator 82 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · 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 | 1.4 |
1.2
0.2 pts worse
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.7 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.6 |
1.5
2.1 pts worse
|
1.8
1.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 4.4 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
96.8%
1.6 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 93.5% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.4% |
98.0%
3.6 pts worse
|
95.5%
1.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
2.6%
2.2 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 3.3% · Q4 12.9% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 19.1% |
16.1%
3 pts worse
|
11.4%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 14.8% · Q3 25.9% · Q4 14.3% · 4Q avg 19.1% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
3.8%
1.1 pts worse
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.9% · Q3 0.0% · Q4 6.7% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.0% |
24.1%
6.9 pts worse
|
19.6%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 27.6% · Q3 30.0% · Q4 45.2% · 4Q avg 31.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.0% |
15.4%
3.6 pts worse
|
16.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 17.4% · Q3 17.4% · Q4 23.1% · 4Q avg 19.0% · 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 | 11.6% |
18.3%
6.7 pts better
|
16.3%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.3% |
13.6%
3.3 pts better
|
14.9%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 11.5% · Q3 3.7% · Q4 24.1% · 4Q avg 10.3% · 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 0.0% · Q4 3.3% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.3% |
22.4%
3.1 pts better
|
19.8%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 10.4% · Q3 9.8% · Q4 36.7% · 4Q avg 19.3% |
| Percentage of long-stay residents with pressure ulcers | 10.7% |
4.1%
6.6 pts worse
|
5.1%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.6% · Q2 10.9% · Q3 16.1% · Q4 3.2% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.0% |
93.3%
2.3 pts worse
|
81.7%
9.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 97.5% · Q3 100.0% · Q4 63.3% · 4Q avg 91.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.4% |
11.8%
2.4 pts better
|
12.0%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.4% · Observed 11.5% · Expected 13.7% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.1% |
91.0%
4.1 pts better
|
79.7%
15.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.0% |
17.4%
0.6 pts worse
|
23.9%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 23.1% · Expected 30.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-05 · Fire 2023-06-05
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-09-02 · Fire 2021-09-02
3 health deficiencies
Top issue: Infection Control (1 deficiency)
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
2025-05-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-29
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 2025-06-29
D · Potential for more than minimal harm
2025-05-29
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 2025-06-29
E · Potential for more than minimal harm
2023-06-05
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 2023-06-20
E · Potential for more than minimal harm
2023-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-06-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-06-20
E · Potential for more than minimal harm
2021-09-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-17
D · Potential for more than minimal harm
2021-09-02
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2021-10-17
D · Potential for more than minimal harm
2021-09-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-10-17
Penalties and ownership
What sits behind the stars
Ownership
Gunnison Valley Hospital
5% Or Greater Direct Ownership Interest · Organization
Bartholomew, Chase
Operational/Managerial Control · Individual
Brooks, Shallen
Operational/Managerial Control · Individual
Gunnison Valley Hospital
Operational/Managerial Control · Organization
Hadley, Haze
Operational/Managerial Control · Individual
Keele, Eddie
Operational/Managerial Control · Individual
Keele, Eddie
Corporate Officer · Individual
Mission Health Services
Operational/Managerial Control · Organization
Murray, Brian
Operational/Managerial Control · Individual
Murray, Brian
Corporate Officer · Individual
Zimbelman, Michelle
Operational/Managerial Control · Individual
Zimbelman, Michelle
Corporate Officer · Individual
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#2
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#3
Mervyn Sharp Bennion Central Utah Veterans Home
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5-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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