Cycle 1
Health 2024-02-28 · Fire 2024-02-28
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Salt Lake City, UT
William E Christofferson Salt Lake Veterans Home
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
700 South Foothill Drive, Salt Lake City, UT
(801) 584-1900
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
81
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avalon Health Care
Operator or chain grouping
Approved since
2000-09-21
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
0.28
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.46
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
4.26
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.85
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
1.32
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.83
CMS adjusted RN staffing hours
Adjusted total hours
5.13
CMS adjusted total nurse staffing hours
Case-mix index
1.14
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,444
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.66
Composite VBP score used to determine payment impact.
Payment multiplier
1.0118
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
5.06
Baseline 54.25% · Performance 42.99% · Measure score 5.06 · Achievement 5.06 · Improvement 3.33
Adjusted total nurse staffing
6.27
Baseline 4 hours · Performance 4.86 hours · Measure score 6.27 · Achievement 6.27 · Improvement 4.34
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 7 · 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 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 12 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 17.79% |
8.2%
9.6 pts better
|
Numerator 29 · Denominator 163 |
| Staff flu vaccination coverage | 90.54% |
42%
48.5 pts better
|
Numerator 201 · Denominator 222 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · 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 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · 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 | 0.1 |
1.2
1.1 pts better
|
1.9
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.1 · Observed 0.1 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0 |
1.5
1.5 pts better
|
1.8
1.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0 · Observed 0 · Expected 1.4 · 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 | 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 | 3.3% |
2.6%
0.7 pts worse
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.0% · Q3 4.3% · Q4 4.3% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.0% |
16.1%
10.1 pts better
|
11.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 16.7% · Q4 5.3% · 4Q avg 6.0% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
3.8%
1.1 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.8% · Q3 1.7% · Q4 3.4% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.5% |
24.1%
12.6 pts better
|
19.6%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 12.5% · Q3 15.0% · Q4 8.6% · 4Q avg 11.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.8% |
15.4%
7.6 pts better
|
16.7%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 8.3% · Q3 3.6% · Q4 7.4% · 4Q avg 7.8% · 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 | 14.4% |
18.3%
3.9 pts better
|
16.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 18.5% · Q3 8.9% · Q4 7.6% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.8% |
13.6%
0.2 pts worse
|
14.9%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 12.5% · Q3 15.3% · Q4 5.2% · 4Q avg 13.8% · 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 2.3% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
1.8%
1.5 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 0.0% · Q3 4.3% · Q4 4.3% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.5% |
22.4%
3.1 pts worse
|
19.8%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 26.1% · Q3 28.4% · Q4 22.5% · 4Q avg 25.5% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.1%
1.5 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 1.5% · Q3 2.8% · Q4 1.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.3%
6.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.7% |
0.9%
2.8 pts worse
|
1.6%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 4.5% · Q4 4.3% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.0%
9 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-09 · Fire 2022-06-09
3 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2019-12-19 · Fire 2019-12-19
13 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-27
D · Potential for more than minimal harm
2022-06-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-06-08
E · Potential for more than minimal harm
2019-12-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-01-31
Inspection history
Recent health citations
G · Actual harm
2025-11-12
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Not marked corrected
D · Potential for more than minimal harm
2024-02-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-14
D · Potential for more than minimal harm
2024-02-28
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-03-14
D · Potential for more than minimal harm
2024-02-28
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 2024-03-14
D · Potential for more than minimal harm
2024-02-28
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 2024-03-14
D · Potential for more than minimal harm
2024-02-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-14
E · Potential for more than minimal harm
2022-06-09
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 2022-06-29
D · Potential for more than minimal harm
2022-06-09
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 2022-06-17
D · Potential for more than minimal harm
2022-06-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-06-24
E · 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 2020-02-14
E · Potential for more than minimal harm
2019-12-19
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 2020-02-14
E · Potential for more than minimal harm
2019-12-19
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 2020-02-14
E · Potential for more than minimal harm
2019-12-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-02-14
E · Potential for more than minimal harm
2019-12-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2020-02-14
E · Potential for more than minimal harm
2019-12-19
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 2020-02-14
D · Potential for more than minimal harm
2019-12-19
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2020-02-14
D · 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 2020-02-14
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 2020-02-14
D · Potential for more than minimal harm
2019-12-19
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 2020-02-14
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 2020-02-14
D · Potential for more than minimal harm
2019-12-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-02-14
D · 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 2020-02-14
Penalties and ownership
What sits behind the stars
Ownership
Avalon Health Care Management, Inc.
Operational/Managerial Control · Organization
Avalon Health Care, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Avalon Holding, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Avalon Va Management LLC
5% Or Greater Direct Ownership Interest · Organization
Avalon Veterans Services, L.l.c.
5% Or Greater Direct Ownership Interest · Organization
Burton, Harold
Corporate Director · Individual
Cooke, Peter
Corporate Director · Individual
Dangerfield, David
Corporate Director · Individual
Franklin, Christie
Corporate Director · Individual
Hash, Alan
Corporate Officer · Individual
Kirton, Charles
5% Or Greater Direct Ownership Interest · Individual
Kirton, Charles
Corporate Director · Individual
Kirton, Charles
Corporate Officer · Individual
Kirton, Hyrum
Corporate Director · Individual
Owens, Mary
Corporate Officer · Individual
Paquette, Sebastian
Corporate Director · Individual
Snow, Noralyn
W-2 Managing Employee · Individual
Stuart, Anne
Corporate Director · Individual
Stuart, Anne
Corporate Officer · Individual
Swinton, Brian
Corporate Director · Individual
Tippets, Carl
Corporate Director · Individual
Woltil, Robert
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
City Creek Post Acute
Salt Lake City, UT
5-star overall rating with 4-star inspections with 2 recent health deficiencies
#2
Maple Ridge Rehabilitation and Nursing
Salt Lake City, UT
2-star overall rating with 2-star inspections with $11,887 in total fines with 14 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Monument Healthcare Cottonwood Creek
Salt Lake City, UT
1-star overall rating with 2-star inspections with $17,940 in total fines with 6 recent health deficiencies
Jump out