9 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Salt Lake City, UT
2-star overall rating with 1-star inspections with $149,703 in total fines with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
2200 East 3300 South, Salt Lake City, UT
(801) 486-2096
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
100
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cascades Healthcare
Operator or chain grouping
Approved since
1977-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.72
Registered nurse staffing
LPN hours / resident day
0.67
Licensed practical nurse staffing
Aide hours / resident day
2.04
Nurse aide staffing
Weekend hours
2.91
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
63%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.5
0.9 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.8% |
96.8%
4 pts worse
|
93.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.0% |
98.0%
1 pts worse
|
95.5%
1.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
2.6%
0.8 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 14.4% |
16.1%
1.7 pts better
|
11.4%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.0% |
3.8%
1.8 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.6% |
24.1%
5.5 pts better
|
19.6%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 4.3% |
15.4%
11.1 pts better
|
16.7%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.6% |
18.3%
3.7 pts better
|
16.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.8% |
13.6%
0.2 pts worse
|
14.9%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.8%
0.1 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.5% |
22.4%
2.9 pts better
|
19.8%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
4.1%
2.2 pts worse
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.6% |
93.3%
4.7 pts worse
|
81.7%
6.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
0.9%
0.2 pts worse
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.2% |
91.0%
3.8 pts worse
|
79.7%
7.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2024-07-07
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-08
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-01
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-05-28
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-07-07
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-07-07
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-28
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 2024-05-08
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-03-09
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-03-15
Fire Safety
Meet other general requirements.
Corrected 2023-03-15
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 2023-02-06
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-09
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-03
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-15
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-13
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-15
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-02-06
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 2021-08-31
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-08-31
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-08-31
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-08-31
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-08-31
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-08-31
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-08-31
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-11-13
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-11-13
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-07-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-08
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-08
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-07-08
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 2024-07-08
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-07-08
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 2024-07-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-07
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-04-07
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-04-07
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 2023-04-07
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-04-07
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-07
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-07
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-04-07
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-07
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-04-07
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2023-04-07
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-04-07
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-07
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-04-07
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-04-07
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-07
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-04-07
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-04-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-07
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 2023-04-07
Health
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
Corrected 2023-04-07
Health
Provide or obtain dental services for each resident.
Corrected 2023-04-07
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2023-04-07
Health
Implement a program that monitors antibiotic use.
Corrected 2023-04-07
Health
Post nurse staffing information every day.
Corrected 2023-04-07
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 2021-09-03
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-09-03
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 2021-09-03
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-09-03
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 2021-09-03
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-09-03
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-09-03
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-09-03
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-03
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2021-09-03
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-09-03
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-09-03
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2021-09-03
Health
Respond appropriately to all alleged violations.
Corrected 2021-09-03
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 2021-09-03
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2021-09-03
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-09-03
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-09-03
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-09-03
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-09-03
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2021-09-03
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 2021-09-03
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2021-09-03
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2021-09-03
Penalties and ownership
Fine · fine $87,712
Fine
Fine · fine $51,503
Fine
Fine · fine $2,797
Fine
Fine · fine $2,447
Fine
Fine · fine $5,244
Fine
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
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