Cycle 1
Health 2023-11-16 · Fire 2023-11-16
8 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Salt Lake City, UT
Monument Healthcare Taylorsville
4-star overall rating with 3-star inspections with $7,525 in total fines with 8 recent health deficiencies
6246 South Redwood Road, Salt Lake City, UT
(801) 969-1420
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
120
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Monument Health Group
Operator or chain grouping
Approved since
1977-07-18
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
0.84
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.59
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
3.47
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.11
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.63
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
0.83
CMS adjusted RN staffing hours
Adjusted total hours
3.40
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,988
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.91
Baseline 19.06% · Performance 21.01% · Measure score 0.91 · Achievement 0.91 · Improvement 0
Healthcare-associated infections
2.25
Baseline 5.30% · Performance 7.16% · Measure score 2.25 · Achievement 2.25 · Improvement 0
Total nurse turnover
0.52
Baseline 52.29% · Performance 61.54% · Measure score 0.52 · Achievement 0.52 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.65 hours · Performance 3.09 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.44% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 103 · Observed rate 9.71% · Lower 95% interval 6.94% |
| Discharge to community | 57.9% |
50.57%
7.3 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 55.67% · Lower 95% interval 48.09% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 49 · Denominator 49 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 49 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 28 · Denominator 42 |
| Discharge mobility score | 69.05% |
50.94%
18.1 pts better
|
Numerator 29 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 49 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.16% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 61 · Observed rate 6.56% · Lower 95% interval 3.8% |
| Staff COVID-19 vaccination coverage | 15.6% |
8.2%
7.4 pts better
|
Numerator 22 · Denominator 141 |
| Staff flu vaccination coverage | 79.83% |
42%
37.8 pts better
|
Numerator 95 · Denominator 119 |
| Discharge function score | 69.05% |
56.45%
12.6 pts better
|
Numerator 29 · Denominator 42 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 87.5% |
96.28%
8.8 pts worse
|
Numerator 28 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · 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 | 99.3% |
96.8%
2.5 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.6% · Q3 98.6% · Q4 100.0% · 4Q avg 99.3% |
| 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 | 2.5% |
2.6%
0.1 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.4% · Q3 4.2% · Q4 2.9% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
16.1%
12.7 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 6.0% · Q3 1.5% · Q4 1.5% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 1.6% |
3.8%
2.2 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 3.0% · Q4 1.7% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.8% |
24.1%
16.3 pts better
|
19.6%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 7.9% · Q3 5.8% · Q4 9.5% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.5% |
15.4%
14.9 pts better
|
16.7%
16.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · 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 | 15.6% |
18.3%
2.7 pts better
|
16.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 10.9% · Q3 12.8% · Q4 18.4% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.0% |
13.6%
9.6 pts better
|
14.9%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.9% · Q3 10.0% · Q4 0.0% · 4Q avg 4.0% · 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 | 1.5% |
1.8%
0.3 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 1.4% · Q4 1.5% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.9% |
22.4%
5.5 pts worse
|
19.8%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.5% · Q2 20.6% · Q3 23.4% · Q4 28.2% · 4Q avg 27.9% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
4.1%
0.3 pts worse
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.9% · Q3 6.0% · Q4 4.9% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
93.3%
2.9 pts better
|
81.7%
14.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.3% · Q2 98.4% · Q3 98.4% · Q4 98.5% · 4Q avg 96.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.2% |
11.8%
9.6 pts better
|
12.0%
9.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.2% · Observed 2.4% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
0.9%
0.7 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
91.0%
5.4 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.3% |
17.4%
3.1 pts better
|
23.9%
9.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 14.3% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-11-17 · Fire 2021-11-17
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-09-12 · Fire 2019-09-12
12 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2021-11-17
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2021-12-01
D · Potential for more than minimal harm
2019-09-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-10-17
Inspection history
Recent health citations
G · Actual harm
2024-03-12
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 2024-03-29
D · Potential for more than minimal harm
2024-03-12
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 2024-03-29
D · Potential for more than minimal harm
2024-03-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-29
E · Potential for more than minimal harm
2023-11-16
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-11-16
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 2024-01-05
E · Potential for more than minimal harm
2023-11-16
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-11-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-16
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-16
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-16
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 2024-01-05
D · Potential for more than minimal harm
2023-11-16
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 2024-01-05
G · Actual harm
2019-09-12
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 2019-10-31
E · Potential for more than minimal harm
2019-09-12
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 2019-10-31
E · Potential for more than minimal harm
2019-09-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-10-31
E · Potential for more than minimal harm
2019-09-12
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2019-10-31
D · Potential for more than minimal harm
2019-09-12
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-10-31
D · Potential for more than minimal harm
2019-09-12
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 2019-10-31
D · Potential for more than minimal harm
2019-09-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-10-31
D · Potential for more than minimal harm
2019-09-12
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 2019-10-31
D · Potential for more than minimal harm
2019-09-12
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 2019-10-31
D · Potential for more than minimal harm
2019-09-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-10-31
D · Potential for more than minimal harm
2019-09-12
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 2019-10-31
D · Potential for more than minimal harm
2019-09-12
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 2019-10-31
Penalties and ownership
What sits behind the stars
$7,525
2024-03-12
Fine
Fine · fine $7,525
Fine
Ownership
Gunnison Valley Hospital
5% Or Greater Direct Ownership Interest · Organization
Cantwell, Kalan
Operational/Managerial Control · Individual
Clawson, Travis
Operational/Managerial Control · Individual
Espinosa, Stephanie
Operational/Managerial Control · Individual
Fragoso, Lindsay
Operational/Managerial Control · Individual
Gangotena-Bernard, Fatima
Operational/Managerial Control · Individual
Gunnison Valley Hospital
Operational/Managerial Control · Organization
Health Group Management LLC
Operational/Managerial Control · Organization
Julian, Meranda
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
Seastrand, Jason
Operational/Managerial Control · Individual
West, Christian
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Cascades at Riverwalk
Midvale, UT
4-star overall rating with 3-star inspections with $23,829 in total fines with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Legacy Village Rehabilitation
Taylorsville, UT
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Aspen Ridge West Transitional Rehab
Murray, UT
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out