Cycle 1
Health 2025-12-11 · Fire 2025-12-11
4 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Bountiful, UT
South Davis Specialty Care
5-star overall rating with 4-star inspections with 4 recent health deficiencies
481 South 400 East, Bountiful, UT
(801) 295-2361
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
95
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2017-08-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 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
Hours and turnover
RN hours / resident day
3.51
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
3.69
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
7.79
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
4.10
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
6.74
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
2.59
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.60
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
3.00
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 52% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.29 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 98% |
95.27%
2.7 pts better
|
Numerator 49 · Denominator 50 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 50 |
| Discharge self-care score | 52.78% |
53.69%
0.9 pts worse
|
Numerator 19 · Denominator 36 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 12 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 50 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 13.9% |
8.2%
5.7 pts better
|
Numerator 51 · Denominator 367 |
| Staff flu vaccination coverage | 91.73% |
42%
49.7 pts better
|
Numerator 388 · Denominator 423 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 18 · Denominator 36 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 53.13% |
25.2%
27.9 pts better
|
Numerator 17 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
96.8%
1 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 100.0% · Q3 100.0% · Q4 94.4% · 4Q avg 97.8% |
| 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 | 1.5% |
2.6%
1.1 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
16.1%
13.4 pts better
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
3.8%
0.9 pts worse
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 3.8% · Q4 11.4% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.3% |
24.1%
10.2 pts worse
|
19.6%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.1% · Q2 35.3% · Q3 28.6% · Q4 36.1% · 4Q avg 34.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.2% |
15.4%
0.2 pts better
|
16.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 13.6% · Q3 18.2% · Q4 15.4% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 2.2% |
0.1%
2.1 pts worse
|
0.1%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.9% · Q3 0.0% · Q4 2.8% · 4Q avg 2.2% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.7% |
18.3%
7.4 pts worse
|
16.3%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.5% |
13.6%
8.9 pts worse
|
14.9%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.9%
0.2 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.8%
1.8 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 8.7% |
22.4%
13.7 pts better
|
19.8%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 9.5% · Q3 19.5% · Q4 4.0% · 4Q avg 8.7% |
| 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 3.2% · Q2 5.5% · Q3 2.3% · Q4 6.3% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
93.3%
1.9 pts better
|
81.7%
13.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.2% · Q2 95.3% · Q3 95.4% · Q4 95.8% · 4Q avg 95.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.9% |
11.8%
12.1 pts worse
|
12.0%
11.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 21.9% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.4% |
0.9%
3.5 pts worse
|
1.6%
2.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 5.9% · Q3 4.6% · Q4 4.3% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.4% |
91.0%
4.4 pts better
|
79.7%
15.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 6.1% |
17.4%
11.3 pts better
|
23.9%
17.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 6.2% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-08 · Fire 2023-11-08
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-12-06 · Fire 2021-12-06
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-11-08
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-15
D · Potential for more than minimal harm
2021-12-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-01-31
D · Potential for more than minimal harm
2021-12-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-01-31
D · Potential for more than minimal harm
2021-12-06
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 2022-02-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-11
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 2026-01-09
D · Potential for more than minimal harm
2025-12-11
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-11
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-11
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 2026-01-09
E · Potential for more than minimal harm
2023-11-08
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 2023-12-15
G · Actual harm
2021-12-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-01-11
E · Potential for more than minimal harm
2021-12-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-11
D · Potential for more than minimal harm
2021-12-06
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 2022-01-11
D · Potential for more than minimal harm
2021-12-06
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 2022-01-11
Penalties and ownership
What sits behind the stars
Ownership
Milestone Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Farnsworth, Stephen
Corporate Director · Individual
Fitch, Craig
Corporate Officer · Individual
Fletcher, Jeff
Operational/Managerial Control · Individual
Fletcher, Jeff
W-2 Managing Employee · Individual
Jenkins, Tracy
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Monument Healthcare Stonecreek
Bountiful, UT
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#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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