13 health deficiencies
Top issue: Administration (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
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
1010 South Medical Drive, Brigham City, UT
(435) 310-5800
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
41
Certified beds
Average residents
38
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mission Health Services
Operator or chain grouping
Approved since
2008-01-28
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
RN hours / resident day
1.17
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.06
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.83
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
4.06
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.04
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.98
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.19
CMS adjusted RN staffing hours
Adjusted total hours
4.12
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Program rank
1,065
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.31
Composite VBP score used to determine payment impact.
Payment multiplier
1.0155
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
7.22
Baseline 16.09% · Performance 18.09% · Measure score 7.22 · Achievement 7.22 · Improvement 0
Healthcare-associated infections
7.97
Baseline 5.13% · Performance 5.45% · Measure score 7.97 · Achievement 7.97 · Improvement 0
Total nurse turnover
1.10
Baseline 71.15% · Performance 63.77% · Measure score 1.10 · Achievement 0 · Improvement 1.10
Adjusted total nurse staffing
7.84
Baseline 4.60 hours · Performance 5.31 hours · Measure score 7.84 · Achievement 7.84 · Improvement 5.52
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.09% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 147 · Observed rate 7.48% · Lower 95% interval 6.97% |
| Discharge to community | 69.1% |
50.57%
18.5 pts better
|
Better than the National Rate · Eligible stays 131 · Observed rate 76.34% · Lower 95% interval 62.71% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 74 · Denominator 74 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 74 |
| Discharge self-care score | 62.5% |
53.69%
8.8 pts better
|
Numerator 40 · Denominator 64 |
| Discharge mobility score | 73.44% |
50.94%
22.5 pts better
|
Numerator 47 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 1.35% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 74 · Adjusted rate 2.06% |
| Healthcare-associated infections requiring hospitalization | 5.45% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 77 · Observed rate 0% · Lower 95% interval 2.73% |
| Staff COVID-19 vaccination coverage | 1.94% |
8.2%
6.3 pts worse
|
Numerator 2 · Denominator 103 |
| Staff flu vaccination coverage | 41.28% |
42%
0.7 pts worse
|
Numerator 45 · Denominator 109 |
| Discharge function score | 53.13% |
56.45%
3.3 pts worse
|
Numerator 34 · Denominator 64 |
| Transfer of health information to provider | 96.88% |
95.95%
0.9 pts better
|
Numerator 62 · Denominator 64 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 17.65% |
25.2%
7.6 pts worse
|
Numerator 6 · Denominator 34 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
96.8%
0.3 pts worse
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 95.2% · Q3 100.0% · Q4 100.0% · 4Q avg 96.5% |
| 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 | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 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 | 3.8% |
16.1%
12.3 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 4.8% · Q4 9.5% · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 12.2% |
3.8%
8.4 pts worse
|
5.4%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 20.0% · 4Q avg 12.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.7% |
24.1%
5.6 pts worse
|
19.6%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 35.0% · 4Q avg 29.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.9% |
15.4%
2.5 pts better
|
16.7%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.9% · 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 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.1% |
18.3%
7.2 pts better
|
16.3%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.7% |
13.6%
5.9 pts better
|
14.9%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.7% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.8%
0.6 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 4.3% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.7% |
22.4%
7.3 pts worse
|
19.8%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 39.5% · Q3 28.6% · Q4 14.0% · 4Q avg 29.7% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.1%
1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 7.3% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
93.3%
2.4 pts better
|
81.7%
14 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.6% · Q2 95.0% · Q3 99.2% · Q4 99.1% · 4Q avg 95.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.2% |
11.8%
1.4 pts worse
|
12.0%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 11.8% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
0.9%
0.2 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 1.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.2% |
91.0%
1.2 pts better
|
79.7%
12.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.5% |
17.4%
1.9 pts better
|
23.9%
8.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.5% · Observed 11.8% · Expected 18.1% · Used in QM five-star |
Survey summary
Top issue: Administration (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Pharmacy Service (4 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Resident Rights (6 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
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 2025-12-31
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-12-31
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-12-31
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-12-31
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-31
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-12-31
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-12-31
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 2024-02-07
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-31
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-01-31
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-12
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-31
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-03-10
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 2022-03-10
Inspection history
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 2025-12-31
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-12
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 2025-12-31
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2025-12-31
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-12-31
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2026-01-16
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-31
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2026-01-16
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-12-31
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-13
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-16
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-12-31
Health
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
Corrected 2025-12-31
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-01-18
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-18
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 2024-01-18
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-18
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-18
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-01-18
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-18
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-18
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 2024-01-18
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-01-18
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-01-18
Health
Implement a program that monitors antibiotic use.
Corrected 2024-01-18
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-15
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-04-15
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2022-04-15
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-04-15
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-04-15
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-04-15
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-04-15
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-04-15
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-04-15
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-04-15
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-04-15
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-04-15
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-04-15
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-04-15
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-04-15
Health
Respond appropriately to all alleged violations.
Corrected 2022-04-15
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2022-04-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-04-15
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2022-04-15
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2022-04-15
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2022-04-15
Penalties and ownership
Fine · fine $40,565
Fine
Payment Denial · denial start 2024-01-06 · 32 days
32 day denial
5% Or Greater Direct Ownership Interest · Organization
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Contracted Managing Employee · Individual
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