Cycle 1
Health 2024-02-22 · Fire 2024-02-22
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Logan, UT
Sunshine Terrace Skilled Nursing
4-star overall rating with 3-star inspections with 5 recent health deficiencies
248 West 300 North, Logan, UT
(435) 752-0411
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
172
Certified beds
Average residents
61
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1981-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.32
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.31
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.81
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
4.44
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.13
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
1.16
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.34
CMS adjusted RN staffing hours
Adjusted total hours
4.51
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,322
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9844
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.74
Baseline 60.56% · Performance 52.50% · Measure score 2.74 · Achievement 2.74 · Improvement 1.76
Adjusted total nurse staffing
2.69
Baseline 3.84 hours · Performance 3.84 hours · Measure score 2.69 · Achievement 2.69 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 23 · 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 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.65 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 20 · Denominator 20 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 20 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 20 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 6.92% |
8.2%
1.3 pts worse
|
Numerator 11 · Denominator 159 |
| Staff flu vaccination coverage | 13.33% |
42%
28.7 pts worse
|
Numerator 28 · Denominator 210 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · 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 | 1.9 |
1.2
0.7 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.6 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.5
0.4 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 68.0% |
96.8%
28.8 pts worse
|
93.4%
25.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 65.0% · Q2 68.3% · Q3 70.9% · Q4 67.9% · 4Q avg 68.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.2% |
98.0%
2.8 pts worse
|
95.5%
0.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
2.6%
1.3 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
16.1%
13 pts better
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.7% · Q3 3.6% · Q4 3.8% · 4Q avg 3.1% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
3.8%
2.1 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 2.4% · Q4 2.3% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.6% |
24.1%
6.5 pts worse
|
19.6%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.4% · Q2 31.9% · Q3 23.3% · Q4 31.1% · 4Q avg 30.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.2% |
15.4%
2.8 pts worse
|
16.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 17.9% · Q3 20.0% · Q4 16.1% · 4Q avg 18.2% · 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 | 17.8% |
18.3%
0.5 pts better
|
16.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 30.3% · Q3 14.4% · Q4 14.7% · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.7% |
13.6%
7.9 pts better
|
14.9%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 13.3% · Q3 2.4% · Q4 2.3% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.9%
0.1 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.4% |
1.8%
2.6 pts worse
|
1.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.0% · Q3 5.6% · Q4 1.9% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.8% |
22.4%
9.4 pts worse
|
19.8%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 30.2% · Q3 33.5% · Q4 31.2% · 4Q avg 31.8% |
| 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 2.7% · Q2 4.9% · Q3 5.2% · Q4 5.1% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 55.3% |
93.3%
38 pts worse
|
81.7%
26.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 45.9% · Q2 51.6% · Q3 63.0% · Q4 57.1% · 4Q avg 55.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 29.2% |
11.8%
17.4 pts worse
|
12.0%
17.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.2% · Observed 31.0% · Expected 11.8% · 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 · Q3 0.0% · Q4 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 | 40.6% |
91.0%
50.4 pts worse
|
79.7%
39.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 40.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.2% |
17.4%
7.8 pts worse
|
23.9%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 27.6% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-19 · Fire 2022-05-19
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-12-19 · Fire 2019-12-19
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2019-12-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-02-02
D · Potential for more than minimal harm
2019-12-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-02-02
D · Potential for more than minimal harm
2019-12-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-02-02
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-02-22
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 2024-04-15
E · Potential for more than minimal harm
2024-02-22
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-04-15
E · Potential for more than minimal harm
2024-02-22
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 2024-04-15
E · Potential for more than minimal harm
2024-02-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-02-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-15
E · Potential for more than minimal harm
2022-05-19
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 2022-07-18
E · Potential for more than minimal harm
2022-05-19
F811 · Nutrition and Dietary Deficiencies
Health
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Corrected 2022-07-18
E · Potential for more than minimal harm
2022-05-19
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 2022-07-18
E · Potential for more than minimal harm
2022-05-19
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 2022-07-18
D · Potential for more than minimal harm
2022-05-19
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-07-18
D · Potential for more than minimal harm
2022-05-19
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 2022-07-18
D · Potential for more than minimal harm
2022-05-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-07-18
D · Potential for more than minimal harm
2022-05-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-07-18
E · Potential for more than minimal harm
2019-12-19
F584 · Resident Rights Deficiencies
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 2020-02-02
E · Potential for more than minimal harm
2019-12-19
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 2020-02-02
E · Potential for more than minimal harm
2019-12-19
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 2020-02-02
E · Potential for more than minimal harm
2019-12-19
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2020-02-02
D · Potential for more than minimal harm
2019-12-19
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 2020-02-02
D · Potential for more than minimal harm
2019-12-19
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 2020-02-02
D · Potential for more than minimal harm
2019-12-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-02-02
D · Potential for more than minimal harm
2019-12-19
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 2020-02-02
D · Potential for more than minimal harm
2019-12-19
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2020-02-02
D · Potential for more than minimal harm
2019-12-19
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2020-02-02
Penalties and ownership
What sits behind the stars
Ownership
Milford Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Barton, Michelle
Corporate Officer · Individual
Erickson, Bryan
Operational/Managerial Control · Individual
Erickson, Bryan
Corporate Officer · Individual
Sunshine Terrace Foundation, Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Logan Regional Hospital Transitional Care Unit
Logan, UT
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Rocky Mountain Care Logan
Logan, UT
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Maple Springs Senior Living
North Logan, UT
1-star overall rating with 2-star inspections with 13 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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