Cycle 1
Health 2024-04-16 · Fire 2024-04-16
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Brigham City, UT
Monument Healthcare Brigham City
3-star overall rating with 2-star inspections with abuse icon flag with 9 recent health deficiencies
775 North 200 East, Brigham City, UT
(435) 723-7777
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
84
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Monument Health Group
Operator or chain grouping
Approved since
1984-08-01
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
1.26
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.17
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.59
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.93
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.23
CMS adjusted RN staffing hours
Adjusted total hours
3.49
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,458
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
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
4.07
Baseline 56.36% · Performance 47.06% · Measure score 4.07 · Achievement 4.07 · Improvement 2.45
Adjusted total nurse staffing
0
Baseline 3.57 hours · Performance 3.10 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.95% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 4.88% · Lower 95% interval 6.45% |
| Discharge to community | 56.77% |
50.57%
6.2 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 56.76% · Lower 95% interval 46.18% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 8 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.61% |
8.2%
6.6 pts worse
|
Numerator 1 · Denominator 62 |
| Staff flu vaccination coverage | 53.64% |
42%
11.6 pts better
|
Numerator 59 · Denominator 110 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| 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 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 4 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.8%
3.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 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 | 15.4% |
16.1%
0.7 pts better
|
11.4%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 15.0% · Q3 17.4% · Q4 13.6% · 4Q avg 15.4% |
| Percentage of long-stay residents who lose too much weight | 7.4% |
3.8%
3.6 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.8% · Q3 9.1% · Q4 11.5% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 43.2% |
24.1%
19.1 pts worse
|
19.6%
23.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 42.9% · Q3 47.8% · Q4 42.3% · 4Q avg 43.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.7% |
15.4%
1.3 pts worse
|
16.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q4 18.2% · 4Q avg 16.7% · 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 | 15.4% |
18.3%
2.9 pts better
|
16.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.3% |
13.6%
8.3 pts better
|
14.9%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 9.5% · Q3 0.0% · Q4 3.8% · 4Q avg 5.3% · 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% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
1.8%
1 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 4.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.5% |
22.4%
4.9 pts better
|
19.8%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 13.5% · Q3 22.8% · Q4 15.4% · 4Q avg 17.5% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
4.1%
1.2 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 10.1% · Q3 3.8% · Q4 2.8% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
93.3%
5.5 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q4 100.0% · 4Q avg 98.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.1% |
0.9%
4.2 pts worse
|
1.6%
3.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 5.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-27 · Fire 2022-06-27
6 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-02-20 · Fire 2020-02-20
5 health deficiencies
Top issue: Administration (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
G · Actual harm
2025-12-03
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 2025-12-20
J · Immediate jeopardy
2024-04-16
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 2024-05-17
F · Potential for more than minimal harm
2024-04-16
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 2024-05-17
E · Potential for more than minimal harm
2024-04-16
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 2024-05-17
E · Potential for more than minimal harm
2024-04-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-04-16
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-16
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-16
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 2024-05-17
D · Potential for more than minimal harm
2024-04-16
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 2024-05-17
E · Potential for more than minimal harm
2022-06-27
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 2022-07-29
E · Potential for more than minimal harm
2022-06-27
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-07-29
E · Potential for more than minimal harm
2022-06-27
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 2022-07-29
D · Potential for more than minimal harm
2022-06-27
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-06-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-06-27
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-07-29
G · Actual harm
2020-02-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-12-04
E · Potential for more than minimal harm
2020-02-20
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2020-03-15
E · Potential for more than minimal harm
2020-02-20
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2020-03-15
D · Potential for more than minimal harm
2020-02-20
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2020-03-06
D · Potential for more than minimal harm
2020-02-20
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2020-03-15
Penalties and ownership
What sits behind the stars
Ownership
Gunnison Valley Hospital
5% Or Greater Direct Ownership Interest · Organization
Clawson, Travis
Operational/Managerial Control · Individual
Espinosa, Stephanie
Operational/Managerial Control · Individual
Fragoso, Lindsay
Operational/Managerial Control · Individual
Gunnison Valley Hospital
Operational/Managerial Control · Organization
Health Group Management LLC
Operational/Managerial Control · Organization
Marriott, Stephen
Operational/Managerial Control · Individual
Monument Health Group LLC
Operational/Managerial Control · Organization
Murray, Brian
Operational/Managerial Control · Individual
Murray, Brian
Corporate Officer · Individual
Nixon, Tyler
Operational/Managerial Control · Individual
Ostermiller, Mercedes
Operational/Managerial Control · Individual
Robertson, Brett
Operational/Managerial Control · Individual
Samuelian, Spencer
Operational/Managerial Control · Individual
Seastrand, Jason
Operational/Managerial Control · Individual
Sims, Braden
Operational/Managerial Control · Individual
West, Christian
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Monument Healthcare Pioneer Trail
Brigham City, UT
4-star overall rating with 3-star inspections with $19,747 in total fines with 8 recent health deficiencies
#2
MSM Brigham City LLC
Brigham City, UT
3-star overall rating with 2-star inspections with $40,565 in total fines with 13 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Sunshine Terrace Skilled Nursing
Logan, UT
4-star overall rating with 3-star inspections with 5 recent health deficiencies
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