Meadow Brook Rehabilitation and Nursing
433 East 2700 South, Salt Lake City, UT 84115
Meadow Brook Rehabilitation and Nursing is a nursing home in Salt Lake City, Utah. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionNovember 20, 2025 (11 months ago)
- Health citations since May 25, 202259 (Utah average 26)
- Fines in the past three years1, $31,331 in total
- CMS flagsCMS abuse icon
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CMS flags
CMS abuse icon
CMS adds this icon when it cites a home for abuse that hurt a resident in the past year. It also adds it when it cites a home for abuse that could have hurt someone, in each of the past two years.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.8 to 3.2 hours per resident per day.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of February 25, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
Health citation
CMS changed citation F0644 from severity G to E. It is from the health inspection on February 22, 2024. Severity E: potential for more than minimal harm, pattern.
Health inspection on November 20, 2025
12 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 12 citations
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for F0812 2 times since 2024.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for F0584 2 times since 2024.
Citation F0775. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep complete, dated laboratory records in the resident's record.
CMS lists it as corrected on December 15, 2025.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for F0804 2 times since 2024.
Citation F0887. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on December 15, 2025.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for F0600 3 times since 2022.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on December 5, 2025.
CMS has cited this home for F0609 3 times since 2022.
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on December 15, 2025.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for F0692 2 times since 2024.
Citation F0770. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely, quality laboratory services/tests to meet the needs of residents.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for F0770 2 times since 2024.
Citation F0773. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
CMS lists it as corrected on December 15, 2025.
Citation F0805. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
CMS lists it as corrected on December 15, 2025.
Fire safety inspection on November 20, 2025
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for E0039 2 times since 2024.
Citation E0004. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on December 15, 2025.
CMS has cited this home for E0004 3 times since 2022.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of July 30, 2025
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on October 24, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 9, 2024.
CMS update of August 29, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 1 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
Fine
CMS changed the fine from February 22, 2024 from $48,200 to $31,330.
April 13, 2024
Payment stoppedCMS stopped payment for new admissions from April 13, 2024, for 6 days.
Health inspection on February 22, 2024
42 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
9 of 97 Utah homes (9%) got a citation at the immediate jeopardy level in 2024.
CMS fine of $31,331 on February 22, 2024.
Show the 42 citations
Citation F0689. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 19, 2024.
Citation F0726. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 19, 2024.
Citation F0867. Severity H: actual harm, pattern.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on April 19, 2024.
Citation F0578. Severity G: actual harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 19, 2024.
Citation F0624. Severity G: actual harm, isolated.
The rule CMS cited:
Prepare residents for a safe transfer or discharge from the nursing home.
CMS lists it as corrected on April 19, 2024.
Citation F0690. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on April 19, 2024.
Citation F0697. Severity G: actual harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on April 19, 2024.
Citation F0740. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
CMS lists it as corrected on April 19, 2024.
Citation F0565. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to organize and participate in resident/family groups in the facility.
CMS lists it as corrected on April 19, 2024.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 19, 2024.
Citation F0600. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on April 19, 2024.
Citation F0607. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on April 19, 2024.
Citation F0609. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on April 19, 2024.
Citation F0610. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on April 19, 2024.
CMS has cited this home for F0610 2 times since 2022.
Citation F0644. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on April 19, 2024.
Citation F0676. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on April 19, 2024.
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on April 19, 2024.
Citation F0728. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 19, 2024.
Citation F0758. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 19, 2024.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 19, 2024.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on April 19, 2024.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 19, 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 19, 2024.
Citation F0881. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on April 19, 2024.
Citation F0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have enough outside ventilation via a window or mechanical ventilation, or both.
CMS lists it as corrected on April 19, 2024.
Citation F0947. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on April 19, 2024.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on April 19, 2024.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on April 19, 2024.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on April 19, 2024.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on April 19, 2024.
Citation F0660. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Plan the resident's discharge to meet the resident's goals and needs.
CMS lists it as corrected on April 19, 2024.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on April 19, 2024.
Citation F0687. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate foot care.
CMS lists it as corrected on April 19, 2024.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on April 19, 2024.
Citation F0694. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
CMS lists it as corrected on April 19, 2024.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on April 19, 2024.
Citation F0745. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS lists it as corrected on April 19, 2024.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on April 19, 2024.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on April 19, 2024.
Citation F0770. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely, quality laboratory services/tests to meet the needs of residents.
CMS lists it as corrected on April 19, 2024.
Citation F0908. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep all essential equipment working safely.
CMS lists it as corrected on April 19, 2024.
Citation F0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS lists it as corrected on April 19, 2024.
Fire safety inspection on February 22, 2024
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation E0004. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on March 29, 2024.
Citation E0039. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on March 29, 2024.
CMS update of January 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Fire safety inspection on October 11, 2023
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on December 6, 2023.
Health inspection on May 25, 2022
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation F0609. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on July 15, 2022.
Citation F0610. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on July 15, 2022.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on July 15, 2022.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on July 15, 2022.
Fire safety inspection on May 25, 2022
1 citationCMS lists this as a standard inspection.
Show the 1 citation
Citation E0004. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on June 16, 2022.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (801) 487-2248
- Last standard health inspection
- November 20, 2025 (11 months ago)
- Certified beds
- 41
- Residents per day, on average
- 31.9
- Ownership type
- Government - Hospital district
- Legal business name
- Beaver Valley Hospital
- Chain
- Cascades Healthcare
- Takes part in
- Medicare and Medicaid
More health citations than the Utah average (59 vs 26).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- CASCADES HEALTHCARE LLCOperational/managerial control · not applicable · since 01/01/2023
- BAIRD, GREGORYOperational/managerial control · not applicable · since 01/01/2023
- HILLS, KYLEOperational/managerial control · not applicable · since 08/28/2025
- MCSPADDEN, DARINOperational/managerial control · not applicable · since 04/01/2014
Questions
When was Meadow Brook Rehabilitation and Nursing last inspected?
CMS lists November 20, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Meadow Brook Rehabilitation and Nursing have?
CMS lists 59 health citations since May 25, 2022. CMS also calls these deficiencies.
Has Meadow Brook Rehabilitation and Nursing been fined?
CMS lists 1 fine in the past three years, $31,331 in total.
What is the CMS star rating of Meadow Brook Rehabilitation and Nursing?
Its CMS overall star rating is 1 of 5.
Is Meadow Brook Rehabilitation and Nursing a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.