Cycle 1
Health 2023-10-05 · Fire 2023-10-05
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Spanish Fork, UT
Spanish Fork Rehabilitation and Nursing
1-star overall rating with 2-star inspections with abuse icon flag with $7,443 in total fines with 3 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
151 East Center Street, Spanish Fork, UT
(801) 798-6220
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
42
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Beaver Valley Hospital
Operator or chain grouping
Approved since
2015-01-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 2 overall / 1 health / 1 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
0.55
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
1.45
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
2.62
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.18
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.36
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
2.69
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
11,366
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.41
Performance 6.82% · Measure score 3.41 · Achievement 3.41 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 3.47 hours · Performance 2.95 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.88% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 5.88% · Lower 95% interval 6.01% |
| Discharge to community | 73% |
50.57%
22.4 pts better
|
Better than the National Rate · Eligible stays 41 · Observed rate 80.49% · Lower 95% interval 57.14% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 91.67% |
95.27%
3.6 pts worse
|
Numerator 22 · Denominator 24 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 24 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 7 · Denominator 21 |
| Discharge mobility score | 52.38% |
50.94%
1.4 pts better
|
Numerator 11 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 24 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.81% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 25 · Observed rate 4% · Lower 95% interval 3.83% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 49 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 47.62% |
56.45%
8.8 pts worse
|
Numerator 10 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · 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 97.1% · Q3 100.0% · 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 | 0.7% |
2.6%
1.9 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.1% |
16.1%
8 pts better
|
11.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 14.7% · Q3 0.0% · Q4 5.1% · 4Q avg 8.1% |
| Percentage of long-stay residents who lose too much weight | 1.5% |
3.8%
2.3 pts better
|
5.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.1% |
24.1%
9 pts better
|
19.6%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 12.5% · Q3 20.0% · Q4 15.8% · 4Q avg 15.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
15.4%
0.6 pts better
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q3 13.6% · Q4 15.4% · 4Q avg 14.8% · 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 | 23.5% |
18.3%
5.2 pts worse
|
16.3%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 26.4% · 4Q avg 23.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.5% |
13.6%
5.9 pts worse
|
14.9%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 16.7% · Q3 36.4% · Q4 15.6% · 4Q avg 19.5% · 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 | 2.8% |
1.8%
1 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.9% · Q3 0.0% · Q4 5.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.4% |
22.4%
3 pts worse
|
19.8%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 30.8% · Q3 31.9% · Q4 13.6% · 4Q avg 25.4% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.1%
1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 3.0% · Q4 5.3% · 4Q avg 3.1% · 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 93.0% · Q2 97.4% · 4Q avg 96.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 27.8% |
11.8%
16 pts worse
|
12.0%
15.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.8% · Observed 28.6% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
0.9%
0.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.5% |
91.0%
3.5 pts worse
|
79.7%
7.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.1% |
17.4%
8.3 pts better
|
23.9%
14.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 9.5% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-11-10 · Fire 2021-11-10
4 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-08-01 · Fire 2019-08-01
5 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-10-05
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-31
F · Potential for more than minimal harm
2023-10-05
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
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 2023-10-31
D · Potential for more than minimal harm
2023-10-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
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 2023-10-31
D · Potential for more than minimal harm
2023-10-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-31
E · Potential for more than minimal harm
2021-11-10
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 2021-11-18
D · Potential for more than minimal harm
2021-11-10
K222 · Egress Deficiencies
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 2021-11-18
D · Potential for more than minimal harm
2019-08-01
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2019-08-30
Inspection history
Recent health citations
G · Actual harm
2023-10-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-10-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-05
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-11-03
E · Potential for more than minimal harm
2021-11-10
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-01-28
D · Potential for more than minimal harm
2021-11-10
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 2022-01-28
D · Potential for more than minimal harm
2021-11-10
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-01-28
D · Potential for more than minimal harm
2021-11-10
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 2022-01-28
E · Potential for more than minimal harm
2019-08-01
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2019-09-27
E · Potential for more than minimal harm
2019-08-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-09-27
E · Potential for more than minimal harm
2019-08-01
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2019-09-27
E · Potential for more than minimal harm
2019-08-01
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 2019-09-27
D · Potential for more than minimal harm
2019-08-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-09-27
Penalties and ownership
What sits behind the stars
$7,443
2023-10-05
Fine
Fine · fine $7,443
Fine
Ownership
Beaver Valley Hospital
5% Or Greater Direct Ownership Interest · Organization
Myers, Walter
Operational/Managerial Control · Individual
Nearby options
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4-star overall rating with 4-star inspections with $4,938 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
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Salem, UT
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Rocky Mountain Care - Maple Dell
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1-star overall rating with 1-star inspections with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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