Cycle 1
Health 2024-04-29 · Fire 2024-04-29
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Bountiful, UT
Monument Healthcare Stonecreek
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
523 North Main Street, Bountiful, UT
(801) 951-2273
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
122
Certified beds
Average residents
77
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Monument Health Group
Operator or chain grouping
Approved since
2004-07-16
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.28
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.40
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.95
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.29
CMS adjusted RN staffing hours
Adjusted total hours
3.74
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
45%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,930
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.23
Baseline 19.79% · Performance 19.47% · Measure score 4.23 · Achievement 4.23 · Improvement 0.65
Healthcare-associated infections
1.63
Baseline 6.93% · Performance 7.35% · Measure score 1.63 · Achievement 1.63 · Improvement 0
Total nurse turnover
0
Baseline 55.13% · Performance 79.17% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.58
Baseline 4.06 hours · Performance 3.53 hours · Measure score 1.58 · Achievement 1.58 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.81% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 154 · Observed rate 9.09% · Lower 95% interval 7.17% |
| Discharge to community | 58.83% |
50.57%
8.3 pts better
|
Better than the National Rate · Eligible stays 128 · Observed rate 62.5% · Lower 95% interval 50.88% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.22% |
95.27%
2 pts better
|
Numerator 70 · Denominator 72 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 72 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 28 · Denominator 56 |
| Discharge mobility score | 30.36% |
50.94%
20.6 pts worse
|
Numerator 17 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 2.78% |
2.29%
0.5 pts worse
|
Numerator 2 · Denominator 72 · Adjusted rate 2.43% |
| Healthcare-associated infections requiring hospitalization | 7.35% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 74 · Observed rate 6.76% · Lower 95% interval 3.87% |
| Staff COVID-19 vaccination coverage | 16.67% |
8.2%
8.5 pts better
|
Numerator 18 · Denominator 108 |
| Staff flu vaccination coverage | 38.67% |
42%
3.3 pts worse
|
Numerator 58 · Denominator 150 |
| Discharge function score | 41.07% |
56.45%
15.4 pts worse
|
Numerator 23 · Denominator 56 |
| Transfer of health information to provider | 98.04% |
95.95%
2.1 pts better
|
Numerator 50 · Denominator 51 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 73.53% |
25.2%
48.3 pts better
|
Numerator 25 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
96.8%
2.7 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.8% · Q4 100.0% · 4Q avg 99.5% |
| 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 | 2.1% |
2.6%
0.5 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.2% · Q3 2.2% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.0% |
16.1%
8.1 pts better
|
11.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 7.3% · Q3 4.7% · Q4 9.3% · 4Q avg 8.0% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
3.8%
1.9 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.9% |
24.1%
1.2 pts better
|
19.6%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 28.6% · Q3 23.7% · Q4 17.6% · 4Q avg 22.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.6% |
15.4%
5.8 pts better
|
16.7%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 7.7% · Q3 13.8% · Q4 7.5% · 4Q avg 9.6% · 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 | 23.3% |
18.3%
5 pts worse
|
16.3%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.8% |
13.6%
0.8 pts better
|
14.9%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.2% · Q3 21.2% · Q4 15.2% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
1.8%
2.5 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 4.4% · Q3 6.7% · Q4 3.5% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.5% |
22.4%
1.9 pts better
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.6% · Q2 20.5% · Q3 18.0% · Q4 15.0% · 4Q avg 20.5% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
4.1%
1.1 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 4.7% · Q3 4.6% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
93.3%
4 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 96.4% · Q3 97.9% · Q4 97.9% · 4Q avg 97.3% |
| 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 8.7% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
0.9%
0.4 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.9% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.1% |
91.0%
1.9 pts worse
|
79.7%
9.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.3% |
17.4%
3.9 pts worse
|
23.9%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.3% · Observed 18.8% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-11 · Fire 2022-07-11
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2020-02-20 · Fire 2020-02-20
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-29
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-05-14
F · Potential for more than minimal harm
2024-04-29
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-05-14
F · Potential for more than minimal harm
2024-04-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-14
F · Potential for more than minimal harm
2024-04-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-29
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-29
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 2024-05-14
D · Potential for more than minimal harm
2024-04-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-14
E · Potential for more than minimal harm
2022-07-11
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 2022-07-29
D · Potential for more than minimal harm
2022-07-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-07-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-07-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-25
E · Potential for more than minimal harm
2020-02-20
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2020-03-02
D · Potential for more than minimal harm
2020-02-20
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 2020-03-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-03
D · Potential for more than minimal harm
2026-01-05
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 2026-02-03
D · Potential for more than minimal harm
2026-01-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-02-03
E · Potential for more than minimal harm
2024-04-29
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 2024-05-14
D · Potential for more than minimal harm
2024-04-29
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 2024-05-14
D · Potential for more than minimal harm
2024-04-29
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-14
D · Potential for more than minimal harm
2024-04-29
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-05-14
G · Actual harm
2024-01-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-01
D · Potential for more than minimal harm
2024-01-03
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 2024-02-01
D · Potential for more than minimal harm
2023-07-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-28
G · Actual harm
2020-02-20
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 2020-01-08
D · Potential for more than minimal harm
2020-02-20
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 2020-03-20
D · Potential for more than minimal harm
2020-02-20
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 2020-03-20
D · Potential for more than minimal harm
2020-02-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-03-20
D · Potential for more than minimal harm
2020-02-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-20
D · Potential for more than minimal harm
2020-02-20
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2020-03-20
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
Galindo, Michael
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
Robertson, Brett
Operational/Managerial Control · Individual
Samuelian, Spencer
Operational/Managerial Control · Individual
Santibanez, Jorge
Operational/Managerial Control · Individual
Seastrand, Jason
Operational/Managerial Control · Individual
West, Christian
Operational/Managerial Control · Individual
West, Shay
Operational/Managerial Control · Individual
Williams, Mark
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
South Davis Specialty Care
Bountiful, UT
5-star overall rating with 4-star inspections with 4 recent health deficiencies
#2
Monument Healthcare Bountiful
Bountiful, UT
2-star overall rating with 2-star inspections with $68,994 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Midtown Manor
Salt Lake City, UT
3-star overall rating with 2-star inspections with 21 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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