D60

Meadow Brook Rehabilitation and Nursing

Grade D 60/100 composite score

Government - Hospital districtSFF CandidateAbuse Citation

CMS Star Ratings

Overall
1/5
Health Insp.
1/5
Quality
4/5
Staffing
3/5
RN Staffing
Not rated

Certified Beds

41

Ownership

Government - Hospital district

Total Fines

$31,331

Last Survey

N/A

433 East 2700 South, Salt Lake City, UT 84115
8014872248

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
1.50h
LPN
0.18h
CNA
2.41h
Total
4.10h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

BEAVER VALLEY HOSPITAL

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Nov 2015

100%

CASCADES HEALTHCARE LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Jan 2023

BAIRD, GREGORY

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jan 2023

HILLS, KYLE

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Aug 2025

MCSPADDEN, DARIN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Apr 2014

BARNEY, JAN

IndividualCORPORATE DIRECTORSince Sep 2018

BROWN, GARY

IndividualCORPORATE DIRECTORSince Sep 2018

OAKDEN, RICHARD

IndividualCORPORATE DIRECTORSince Sep 2018

ROBINSON, MATTHEW

IndividualCORPORATE DIRECTORSince Sep 2018

SMITH, VAL

IndividualCORPORATE DIRECTORSince Sep 2018

WHITE, CRAIG

IndividualCORPORATE DIRECTORSince Sep 2018

LANGFORD, SCOTT

IndividualCORPORATE OFFICERSince Jul 2014

MCSPADDEN, DARIN

IndividualCORPORATE OFFICERSince Apr 2014

Penalties & Fines (2)

$31,331total fines
DateTypeDescriptionAmount
Feb 22, 2024Fine$31,331
Feb 22, 2024Payment Denial

Health Inspection Deficiencies (55)

November 20, 2025Health2 deficiencies
0600DMinimal harm, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Dec 15, 2025
0887EMinimal harm, Pattern

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Infection Control Deficiencies

Corrected Dec 15, 2025
October 24, 2024Health1 deficiency
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Dec 9, 2024
February 22, 2024Health42 deficiencies9 severe
0679DMinimal harm, Isolated

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Corrected Apr 19, 2024
0660DMinimal harm, Isolated

Plan the resident's discharge to meet the resident's goals and needs.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 19, 2024
0687DMinimal harm, Isolated

Provide appropriate foot care.

Quality of Life and Care Deficiencies

Corrected Apr 19, 2024
0676EMinimal harm, Pattern

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Corrected Apr 19, 2024
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Apr 19, 2024
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Apr 19, 2024
0565EMinimal harm, Pattern

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Corrected Apr 19, 2024
0578GActual harm, Isolated

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies

Corrected Apr 19, 2024
0580DMinimal harm, Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies

Corrected Apr 19, 2024
0584EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Apr 19, 2024
0600EMinimal harm, Pattern

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Apr 19, 2024
0607EMinimal harm, Pattern

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Apr 19, 2024
0609EMinimal harm, Pattern

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Apr 19, 2024
0610EMinimal harm, Pattern

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Apr 19, 2024
0624GActual harm, Isolated

Prepare residents for a safe transfer or discharge from the nursing home.

Resident Rights Deficiencies

Corrected Apr 19, 2024
0644GActual harm, Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 19, 2024
0657DMinimal harm, Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Corrected Apr 19, 2024
0689JImmediate jeopardy, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Apr 19, 2024
0690GActual harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Apr 19, 2024
0692DMinimal harm, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Apr 19, 2024
0694DMinimal harm, Isolated

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Apr 19, 2024
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Apr 19, 2024
0697GActual harm, Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Apr 19, 2024
0725EMinimal harm, Pattern

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies

Corrected Apr 19, 2024
0726JImmediate jeopardy, Isolated

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Nursing and Physician Services Deficiencies

Corrected Apr 19, 2024
0728EMinimal harm, Pattern

Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.

Nursing and Physician Services Deficiencies

Corrected Apr 19, 2024
0740GActual harm, Isolated

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Quality of Life and Care Deficiencies

Corrected Apr 19, 2024
0745DMinimal harm, Isolated

Provide medically-related social services to help each resident achieve the highest possible quality of life.

Quality of Life and Care Deficiencies

Corrected Apr 19, 2024
0757DMinimal harm, Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

Corrected Apr 19, 2024
0758EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Apr 19, 2024
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Apr 19, 2024
0761EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Apr 19, 2024
0770DMinimal harm, Isolated

Provide timely, quality laboratory services/tests to meet the needs of residents.

Administration Deficiencies

Corrected Apr 19, 2024
0804EMinimal harm, Pattern

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Corrected Apr 19, 2024
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Apr 19, 2024
0867HActual harm, Pattern

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Administration Deficiencies

Corrected Apr 19, 2024
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Apr 19, 2024
0881EMinimal harm, Pattern

Implement a program that monitors antibiotic use.

Infection Control Deficiencies

Corrected Apr 19, 2024
0908DMinimal harm, Isolated

Keep all essential equipment working safely.

Environmental Deficiencies

Corrected Apr 19, 2024
0919DMinimal harm, Isolated

Make sure that a working call system is available in each resident's bathroom and bathing area.

Environmental Deficiencies

Corrected Apr 19, 2024
0923EMinimal harm, Pattern

Have enough outside ventilation via a window or mechanical ventilation, or both.

Environmental Deficiencies

Corrected Apr 19, 2024
0947EMinimal harm, Pattern

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Nursing and Physician Services Deficiencies

Corrected Apr 19, 2024
May 25, 2022Health4 deficiencies
0610EMinimal harm, Pattern

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 15, 2022
0600DMinimal harm, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 15, 2022
0609EMinimal harm, Pattern

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Jul 15, 2022
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Jul 15, 2022
December 18, 2019Health6 deficiencies1 severe
0578DMinimal harm, Isolated

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies

Corrected Feb 6, 2020
0584EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Feb 6, 2020
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Feb 6, 2020
0685DMinimal harm, Isolated

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Corrected Feb 6, 2020
0689GActual harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Feb 6, 2020
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Feb 6, 2020

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Frequently Asked Questions

What is the CareGrader rating for Meadow Brook Rehabilitation and Nursing?

Meadow Brook Rehabilitation and Nursing in Salt Lake City, Utah has a CareGrader grade of D (Below Average), with a composite score of 60.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for Meadow Brook Rehabilitation and Nursing?

Meadow Brook Rehabilitation and Nursing has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 3/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does Meadow Brook Rehabilitation and Nursing have?

Meadow Brook Rehabilitation and Nursing has 55 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). This facility has abuse citations on record. View the full inspection timeline above for details on each deficiency.

Has Meadow Brook Rehabilitation and Nursing been fined?

Yes. Meadow Brook Rehabilitation and Nursing has $31,331 in total fines from CMS enforcement actions across 2 penalties.

How many beds does Meadow Brook Rehabilitation and Nursing have?

Meadow Brook Rehabilitation and Nursing has 41 certified beds with approximately 28 current residents (68% occupancy). The facility is located at 433 East 2700 South, Salt Lake City, Utah 84115. It is a government - hospital district facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.