MSM Brigham City LLC

1010 South Medical Drive
Brigham City, UT, 84302
4353105800
CCN: 465165
3
Overall
2
Health
4
Staffing
5
Quality
ChainMISSION HEALTH SERVICES
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
GUNNISON VALLEY HOSPITAL5% OR GREATER DIRECT OWNERSHIP INTEREST100%
STURDEVANT, BRANDONCONTRACTED MANAGING EMPLOYEENOT APPLICABLE
PICKETT, KIMCORPORATE DIRECTORNOT APPLICABLE
DYRENG, CASEYCORPORATE DIRECTORNOT APPLICABLE
SORENSON, MERRI LYNNCORPORATE DIRECTORNOT APPLICABLE
ANDERSEN, JEANETTECORPORATE DIRECTORNOT APPLICABLE
ANDERSON, STEVECORPORATE DIRECTORNOT APPLICABLE
BARTHOLOMEW, LAMARCORPORATE DIRECTORNOT APPLICABLE
BLACKHAM, BRADYCORPORATE DIRECTORNOT APPLICABLE
BARTHOLOMEW, BRENDACORPORATE OFFICERNOT APPLICABLE
MURRAY, BRIANCORPORATE OFFICERNOT APPLICABLE
MSM BRIGHAM CITYOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
LARSEN, GREGORYOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
LARSEN, NICHOLASOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
DUNN, MARCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Penalties (2)
DateTypeAmount
2023-12-18Fine$41K
2023-12-18Payment Denial32 days
Health Deficiencies (47)
2025-12-15 · Health
E
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F804 · Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
E
F801 · Nutrition and Dietary Deficiencies
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.
D
F779 · Administration Deficiencies
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
E
F775 · Administration Deficiencies
Keep complete, dated laboratory records in the resident's record.
D
F773 · Administration Deficiencies
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
E
F761 · Pharmacy Service Deficiencies
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.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
G
F690 · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F628 · Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
D
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
2023-12-18 · Health
D
F881 · Infection Control Deficiencies
Implement a program that monitors antibiotic use.
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F770 · Administration Deficiencies
Provide timely, quality laboratory services/tests to meet the needs of residents.
E
F761 · Pharmacy Service Deficiencies
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.
D
F757 · Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
D
F756 · Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
E
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
G
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
D
F554 · Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
2022-03-02 · Health
E
F888 · Infection Control Deficiencies
Ensure staff are vaccinated for COVID-19
L
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F867 · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
E
F835 · Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
D
F825 · Quality of Life and Care Deficiencies
Provide or get specialized rehabilitative services as required for a resident.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
D
F745 · Quality of Life and Care Deficiencies
Provide medically-related social services to help each resident achieve the highest possible quality of life.
D
F729 · Nursing and Physician Services Deficiencies
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F622 · Resident Rights Deficiencies
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.
D
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
E
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
G
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
J
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
E
F585 · Resident Rights Deficiencies
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.
D
F583 · Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
D
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
D
F561 · Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
D
F554 · Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
4.06
3.68
RN Hrs/Resident/Day
1.17
0.54
LPN Hrs/Resident/Day
0.06
0.81
CNA Hrs/Resident/Day
2.83
2.33
PT Hrs/Resident/Day
0.15
0.12
Data as of 2026-03-01