Cycle 1
Health 2025-05-20 · Fire 2025-05-20
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Ivins, UT
Southern Utah Veterans Home - Ivins
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
160 North 200 East, Ivins, UT
(435) 634-5220
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avalon Health Care
Operator or chain grouping
Approved since
2013-08-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 4 overall / 3 health / 4 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
1.52
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
3.44
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
5.83
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
2.39
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
5.23
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
1.36
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.81
CMS adjusted RN staffing hours
Adjusted total hours
6.91
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,289
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.95
Composite VBP score used to determine payment impact.
Payment multiplier
1.0131
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.60
Performance 19.77% · Measure score 3.60 · Achievement 3.60 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.14
Performance 6.60% · Measure score 4.14 · Achievement 4.14 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
5.45
Baseline 52.35% · Performance 41.42% · Measure score 5.45 · Achievement 5.45 · Improvement 3.47
Adjusted total nurse staffing
10
Baseline 5.54 hours · Performance 5.93 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.17% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 7.55% · Lower 95% interval 6.83% |
| Discharge to community | 47.81% |
50.57%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 44.74% · Lower 95% interval 33.82% |
| Medicare spending per beneficiary | 1.35 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 82.35% |
95.27%
12.9 pts worse
|
Numerator 28 · Denominator 34 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 34 |
| Discharge self-care score | 30% |
53.69%
23.7 pts worse
|
Numerator 9 · Denominator 30 |
| Discharge mobility score | 20% |
50.94%
30.9 pts worse
|
Numerator 6 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 34 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.6% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 3.45% · Lower 95% interval 3.6% |
| Staff COVID-19 vaccination coverage | 0.43% |
8.2%
7.8 pts worse
|
Numerator 1 · Denominator 232 |
| Staff flu vaccination coverage | 78.62% |
42%
36.6 pts better
|
Numerator 375 · Denominator 477 |
| Discharge function score | 20% |
56.45%
36.5 pts worse
|
Numerator 6 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| 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 |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.2
0.1 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.8%
3.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.9% |
98.0%
1.1 pts worse
|
95.5%
1.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
2.6%
1.2 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 4.4% · Q3 3.4% · Q4 4.3% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.5% |
16.1%
3.6 pts better
|
11.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 13.6% · Q3 8.8% · Q4 6.7% · 4Q avg 12.5% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
3.8%
1.4 pts worse
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.1% · Q3 4.2% · Q4 8.7% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.6% |
24.1%
5.5 pts worse
|
19.6%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 24.7% · Q3 40.8% · Q4 40.6% · 4Q avg 29.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.9% |
15.4%
3.5 pts better
|
16.7%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 10.0% · Q3 11.9% · Q4 15.0% · 4Q avg 11.9% · 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 · 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 | 19.3% |
18.3%
1 pts worse
|
16.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 27.7% · Q3 13.9% · Q4 10.5% · 4Q avg 19.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.5% |
13.6%
4.9 pts worse
|
14.9%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 30.6% · Q3 10.0% · Q4 11.8% · 4Q avg 18.5% · 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 | 1.1% |
1.8%
0.7 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 2.2% · Q4 1.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.6% |
22.4%
2.8 pts better
|
19.8%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 25.9% · Q3 19.8% · Q4 12.1% · 4Q avg 19.6% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
4.1%
2.3 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 2.4% · Q3 2.6% · Q4 1.2% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
93.3%
5.1 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 98.6% · Q3 98.5% · Q4 98.3% · 4Q avg 98.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.9% |
11.8%
3.1 pts worse
|
12.0%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.9% · Observed 14.3% · Expected 10.7% · 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 2.6% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.3% |
91.0%
3.3 pts better
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.9% |
17.4%
0.5 pts worse
|
23.9%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 17.1% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-28 · Fire 2023-06-28
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2021-09-29 · Fire 2021-09-29
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-20
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 2025-06-23
D · Potential for more than minimal harm
2025-05-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-23
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-07-01
E · Potential for more than minimal harm
2025-05-20
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-05-20
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 2025-07-01
D · Potential for more than minimal harm
2025-05-20
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 2025-07-01
D · Potential for more than minimal harm
2025-05-20
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-05-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-05-20
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 2025-07-01
D · Potential for more than minimal harm
2025-05-20
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-05-20
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 2025-07-01
D · Potential for more than minimal harm
2025-05-20
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 2025-07-01
D · Potential for more than minimal harm
2025-05-20
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 2025-07-01
D · Potential for more than minimal harm
2023-06-28
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-07-31
Penalties and ownership
What sits behind the stars
Ownership
Avalon Va Management LLC
5% Or Greater Direct Ownership Interest · Organization
Avalon Health Care Management, Inc.
Operational/Managerial Control · Organization
Avalon Health Care, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Avalon Health Care, Inc.
Operational/Managerial Control · Organization
Avalon Holding, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Avalon Veterans Services, L.l.c.
5% Or Greater Indirect Ownership Interest · Organization
Borisevich, Maria
Operational/Managerial Control · Individual
Borisevich, Maria
Corporate Officer · Individual
Brereton, Dean
Operational/Managerial Control · Individual
Dangerfield, David
Corporate Director · Individual
Hash, Alan
Operational/Managerial Control · Individual
Hash, Alan
Corporate Officer · Individual
Hyrum A Kirton Individual Tr
5% Or Greater Indirect Ownership Interest · Organization
K-Team LLC
5% Or Greater Indirect Ownership Interest · Organization
Kirton, Byron
5% Or Greater Indirect Ownership Interest · Individual
Kirton, Byron
Corporate Director · Individual
Kirton, Charles
Operational/Managerial Control · Individual
Kirton, Charles
Corporate Director · Individual
Kirton, Charles
Corporate Officer · Individual
Kirton, Hyrum
5% Or Greater Indirect Ownership Interest · Individual
Kirton, Hyrum
Operational/Managerial Control · Individual
Kirton, Hyrum
Corporate Director · Individual
Kirton, Hyrum
Corporate Officer · Individual
Kirton, Spencer
5% Or Greater Indirect Ownership Interest · Individual
Kirton, Spencer
Corporate Director · Individual
Olson, Jerry
Operational/Managerial Control · Individual
Sabol, Dusan
Operational/Managerial Control · Individual
Smith, Nicole
Operational/Managerial Control · Individual
Smith, Nicole
Corporate Officer · Individual
Spencer K Kirton Individual Tr
5% Or Greater Indirect Ownership Interest · Organization
State Of Utah
Operational/Managerial Control · Organization
The Byron A Kirton Individual Tr
5% Or Greater Indirect Ownership Interest · Organization
Woltil, Robert
Corporate Director · Individual
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#2
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#3
Bella Terra St George
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