Cycle 1
Health 2024-08-29 · Fire 2024-08-29
14 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Ogden, UT
The Terrace Transitional
3-star overall rating with 2-star inspections with 14 recent health deficiencies
400 East 5350 South, Ogden, UT
(801) 479-9855
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
120
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1987-10-09
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
0.67
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.29
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.78
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
3.48
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,589
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.66
Baseline 21.85% · Performance 20.33% · Measure score 2.66 · Achievement 2.38 · Improvement 2.66
Healthcare-associated infections
1.28
Baseline 6.84% · Performance 7.45% · Measure score 1.28 · Achievement 1.28 · Improvement 0
Total nurse turnover
2.53
Baseline 54.84% · Performance 53.33% · Measure score 2.53 · Achievement 2.53 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.29 hours · Performance 2.93 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.07% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 57 · Observed rate 8.77% · Lower 95% interval 6.38% |
| Discharge to community | 48.13% |
50.57%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 45.24% · Lower 95% interval 32.26% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 86.49% |
95.27%
8.8 pts worse
|
Numerator 32 · Denominator 37 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 37 |
| Discharge self-care score | 48.39% |
53.69%
5.3 pts worse
|
Numerator 15 · Denominator 31 |
| Discharge mobility score | 32.26% |
50.94%
18.7 pts worse
|
Numerator 10 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 2.7% |
2.29%
0.4 pts worse
|
Numerator 1 · Denominator 37 · Adjusted rate 2.75% |
| Healthcare-associated infections requiring hospitalization | 7.45% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 9.68% · Lower 95% interval 3.91% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 133 |
| Staff flu vaccination coverage | 50.29% |
42%
8.3 pts better
|
Numerator 87 · Denominator 173 |
| Discharge function score | 45.16% |
56.45%
11.3 pts worse
|
Numerator 14 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · 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 18 · 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 | 1.0 |
1.2
0.2 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.4 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.5
0.8 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.8 · Expected 2.1 · Used in QM five-star |
| 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 98.7% · Q2 98.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
98.0%
0.8 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
2.6%
0.3 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 2.7% · Q3 1.3% · Q4 1.3% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 44.3% |
16.1%
28.2 pts worse
|
11.4%
32.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.2% · Q2 44.3% · Q3 48.6% · Q4 47.9% · 4Q avg 44.3% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
3.8%
0.2 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 7.1% · Q3 0.0% · Q4 4.2% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.2% |
24.1%
14.1 pts worse
|
19.6%
18.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.3% · Q2 38.0% · Q3 37.0% · Q4 37.5% · 4Q avg 38.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.2% |
15.4%
2.2 pts better
|
16.7%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 14.3% · Q3 9.5% · Q4 17.0% · 4Q avg 13.2% · 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 | 20.3% |
18.3%
2 pts worse
|
16.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 18.8% · Q4 10.1% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.5% |
13.6%
2.9 pts worse
|
14.9%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.2% · Q2 13.3% · Q3 12.3% · Q4 5.0% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.9%
0.4 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 3.7% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.8%
0.1 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.4% · Q3 1.4% · Q4 1.3% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.1% |
22.4%
8.3 pts better
|
19.8%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 12.4% · Q3 19.4% · Q4 12.1% · 4Q avg 14.1% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
4.1%
0.7 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.8% · Q3 1.2% · Q4 6.6% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.9% |
93.3%
6.4 pts worse
|
81.7%
5.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.2% · Q2 84.3% · Q3 85.9% · Q4 88.0% · 4Q avg 86.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
11.8%
4.3 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 7.9% · 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 · Q1 0.0% · Q2 0.0% · 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 | 88.9% |
91.0%
2.1 pts worse
|
79.7%
9.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 7.2% |
17.4%
10.2 pts better
|
23.9%
16.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.2% · Observed 7.9% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-15 · Fire 2022-12-15
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 2021-05-06 · Fire 2021-05-06
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-27
E · Potential for more than minimal harm
2024-08-29
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-10-23
E · Potential for more than minimal harm
2024-08-29
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-10-23
E · Potential for more than minimal harm
2024-08-29
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-10-23
E · Potential for more than minimal harm
2024-08-29
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-10-23
E · Potential for more than minimal harm
2024-08-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-10-23
E · Potential for more than minimal harm
2024-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-08-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-08-29
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-08-29
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-08-29
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-08-29
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 2024-10-23
D · Potential for more than minimal harm
2024-08-29
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 2024-10-23
D · Potential for more than minimal harm
2024-08-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-10-23
D · Potential for more than minimal harm
2024-08-29
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 2024-10-23
D · Potential for more than minimal harm
2024-08-29
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-10-23
D · Potential for more than minimal harm
2023-03-16
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-05-02
E · Potential for more than minimal harm
2022-12-15
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 2023-02-20
E · Potential for more than minimal harm
2022-12-15
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-02-20
E · Potential for more than minimal harm
2022-12-15
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 2023-02-20
D · Potential for more than minimal harm
2022-12-15
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 2023-02-20
D · Potential for more than minimal harm
2022-12-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-02-20
D · Potential for more than minimal harm
2022-12-15
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-02-20
F · Potential for more than minimal harm
2021-05-06
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 2021-06-17
E · Potential for more than minimal harm
2021-05-06
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 2021-06-17
D · Potential for more than minimal harm
2021-05-06
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2021-06-17
D · Potential for more than minimal harm
2021-05-06
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 2021-06-17
Penalties and ownership
What sits behind the stars
Ownership
Beaver Valley Hospital
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Delahunty, Colin
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Moss, Tyler
Corporate Officer · Individual
Stelter, Casey
Operational/Managerial Control · Individual
Waterfall Canyon Healthcare, Inc.
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Mt Ogden Health and Rehabilitation Center
Washington Terrace, UT
4-star overall rating with 4-star inspections with 5 recent health deficiencies
#2
Stonehenge of Ogden
Washington Terrace, UT
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
South Ogden Post-Acute
Ogden, UT
1-star overall rating with 1-star inspections with Special Focus status with $264,268 in total fines with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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