Cycle 1
Health 2024-07-16 · Fire 2024-07-16
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Salt Lake City, UT
St Joseph Villa
3-star overall rating with 3-star inspections with 5 recent health deficiencies
451 East Bishop Federal Lane, Salt Lake City, UT
(801) 487-7557
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
221
Certified beds
Average residents
175
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1984-10-01
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
0.90
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.43
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.52
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.85
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.39
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.54
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
0.80
CMS adjusted RN staffing hours
Adjusted total hours
3.44
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
19%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,938
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9950
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.60
Baseline 19.89% · Performance 18.38% · Measure score 6.60 · Achievement 6.60 · Improvement 4.79
Healthcare-associated infections
1.75
Baseline 5.52% · Performance 7.31% · Measure score 1.75 · Achievement 1.75 · Improvement 0
Total nurse turnover
8.48
Baseline 44.80% · Performance 29.03% · Measure score 8.48 · Achievement 8.48 · Improvement 7.40
Adjusted total nurse staffing
0
Baseline 3.10 hours · Performance 3.13 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.01% |
10.72%
2.7 pts better
|
Better than the National Rate · Eligible stays 280 · Observed rate 5.71% · Lower 95% interval 5.82% |
| Discharge to community | 70.53% |
50.57%
20 pts better
|
Better than the National Rate · Eligible stays 226 · Observed rate 66.81% · Lower 95% interval 62.54% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.22% |
95.27%
2 pts better
|
Numerator 210 · Denominator 216 |
| Falls with major injury | 1.39% |
0.77%
0.6 pts worse
|
Numerator 3 · Denominator 216 |
| Discharge self-care score | 68.55% |
53.69%
14.9 pts better
|
Numerator 109 · Denominator 159 |
| Discharge mobility score | 62.89% |
50.94%
12 pts better
|
Numerator 100 · Denominator 159 |
| Pressure ulcers or injuries, new or worsened | 6.48% |
2.29%
4.2 pts worse
|
Numerator 14 · Denominator 216 · Adjusted rate 5.7% |
| Healthcare-associated infections requiring hospitalization | 7.31% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 166 · Observed rate 7.23% · Lower 95% interval 5.2% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 279 |
| Staff flu vaccination coverage | 53.47% |
42%
11.5 pts better
|
Numerator 185 · Denominator 346 |
| Discharge function score | 72.33% |
56.45%
15.9 pts better
|
Numerator 115 · Denominator 159 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 113 · Denominator 113 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 51 · Denominator 51 |
| Resident COVID-19 vaccinations up to date | 9.09% |
25.2%
16.1 pts worse
|
Numerator 9 · Denominator 99 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.2
0.7 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.3 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
96.8%
3 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.3% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.3% |
98.0%
1.3 pts better
|
95.5%
3.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
2.6%
1.6 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 3.7% · Q3 3.0% · Q4 4.9% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.9% |
16.1%
2.2 pts better
|
11.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 14.3% · Q3 19.0% · Q4 12.0% · 4Q avg 13.9% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
3.8%
1.7 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.3% · Q3 0.0% · Q4 4.3% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.9% |
24.1%
7.2 pts better
|
19.6%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 16.9% · Q3 15.8% · Q4 18.6% · 4Q avg 16.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.3% |
15.4%
3.1 pts better
|
16.7%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 11.5% · Q3 12.2% · Q4 14.4% · 4Q avg 12.3% · 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 | 33.8% |
18.3%
15.5 pts worse
|
16.3%
17.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.4% · Q2 35.2% · Q3 42.1% · Q4 25.3% · 4Q avg 33.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.3% |
13.6%
5.7 pts worse
|
14.9%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 30.2% · Q3 16.7% · Q4 19.8% · 4Q avg 19.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.6% · Q3 0.0% · Q4 0.5% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.8%
0.9 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.0% |
22.4%
5.6 pts worse
|
19.8%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 31.5% · Q3 25.6% · Q4 29.1% · 4Q avg 28.0% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
4.1%
2.6 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.8% · Q3 4.8% · Q4 6.7% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.3% |
93.3%
2 pts worse
|
81.7%
9.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 93.3% · Q3 91.8% · Q4 85.0% · 4Q avg 91.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.1% |
11.8%
1.3 pts worse
|
12.0%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 15.6% · Expected 13.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
0.9%
About the same
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 1.8% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.6% |
91.0%
1.4 pts worse
|
79.7%
9.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.5% |
17.4%
2.1 pts worse
|
23.9%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 24.4% · Expected 29.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-09-01 · Fire 2022-09-01
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-03-04 · Fire 2020-03-04
4 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2020-03-04
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2020-03-18
Inspection history
Recent health citations
G · Actual harm
2024-07-16
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 2023-10-23
E · Potential for more than minimal harm
2024-07-16
F801 · Nutrition and Dietary Deficiencies
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 2024-09-06
E · Potential for more than minimal harm
2024-07-16
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 2024-09-06
D · Potential for more than minimal harm
2024-07-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-07-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-07-16
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-09-06
G · Actual harm
2022-09-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-17
G · Actual harm
2022-09-01
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 2022-09-01
D · Potential for more than minimal harm
2022-09-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-09-01
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-10-17
E · Potential for more than minimal harm
2020-03-04
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2020-03-29
E · Potential for more than minimal harm
2020-03-04
F761 · Pharmacy Service Deficiencies
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 2020-03-29
E · Potential for more than minimal harm
2020-03-04
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 2020-03-29
E · Potential for more than minimal harm
2020-03-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-29
Penalties and ownership
What sits behind the stars
Ownership
Beaver Valley Hospital
5% Or Greater Direct Ownership Interest · Organization
Albrechtsen, Brad
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Davidson, Craig
Corporate Officer · Individual
Gangotena-Bernard, Fatima
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Moss, Tyler
Corporate Officer · Individual
Successor Healthcare LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Monument Healthcare South Salt Lake
Salt Lake City, UT
1-star overall rating with 1-star inspections with Special Focus status with $31,391 in total fines with 20 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Meadow Brook Rehabilitation and Nursing
Salt Lake City, UT
1-star overall rating with 1-star inspections with abuse icon flag with $31,331 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Little Cottonwood Rehabilitation and Nursing
South Salt Lake, UT
5-star overall rating with 5-star inspections with 5 recent health deficiencies
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