Heritage Park Healthcare and Rehabilitation
2700 West 5600 South, Roy, UT 84067 · Weber County · 176 certified beds · avg 115 residents/day · certified since Jan 1, 1978
Abuse citation flag (CMS)
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jul 2, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 4, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 2, 2024 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 4, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 15, 2022 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 2, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (27)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jul 2, 2024 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jul 2, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 2, 2024 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Jul 2, 2024 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jul 2, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 2, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jul 2, 2024 | D · Potential for harm, one-off | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Jul 2, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Jul 2, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jul 2, 2024 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Jul 2, 2024 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. |
| Jul 2, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Oct 24, 2023 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Nov 15, 2022 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Nov 15, 2022 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Nov 15, 2022 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Nov 15, 2022 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Nov 15, 2022 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Nov 15, 2022 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Nov 15, 2022 | D · Potential for harm, one-off | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Nov 15, 2022 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 8, 2021 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 8, 2021 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Apr 8, 2021 | E · Potential for harm, repeated | The facility did not have firmly secured handrails on both sides of its hallways. |
| Apr 8, 2021 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Apr 8, 2021 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Apr 8, 2021 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (8 → 12).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 6 | 0 | F |
| 2022 | 8 | 1 | G ▲ |
| 2023 | 1 | 0 | E |
| 2024 | 12 | 2 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $36,645.
| Date | Type | Amount / length |
|---|---|---|
| Jul 2, 2024 | Fine | $36,645 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Utah avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.47 | 3.87 | 3.95 | bottom 39% in Utah; bottom 35% in the U.S. |
| Registered Nurse hours | 0.81 | 1.17 | 0.69 | bottom 22% in Utah; top 27% in the U.S. |
| Weekend total nurse staffing | 3.05 | 3.39 | 3.50 | bottom 41% in Utah; bottom 34% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.53 | 0.88 | 0.48 | bottom 18% in Utah; top 29% in the U.S. |
| Total nursing staff turnover (%) | 46.8 | 50.7 | 45.8 | top 38% in Utah; bottom 45% in the U.S. |
| RN turnover (%) | 23.1 | 40.6 | 42.9 | top 19% in Utah; top 18% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.84, RN 0.90, weekend 3.38. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 4/5 · short-stay residents: 5/5
Who owns this facility
For profit - Partnership
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 06/01/2017 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2017 |
| Fletcher, Jeff | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2017 |
| Fletcher, Jeff | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/01/2017 |
| Fletcher, Jeff | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2017 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Moss, Tyler | Individual | Corporate Officer | NOT APPLICABLE | 06/01/2017 |
| Standard Bearer Healthcare Op, LP | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2017 |
| Stelter, Casey | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/24/2018 |
| Stelter, Casey | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/24/2018 |
| Stelter, Casey | Individual | ADP of the SNF | NOT APPLICABLE | 01/24/2018 |
| The Ensign Group INC | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2017 |
| West 5600 Health Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2017 |
| West 5600 Healthcare LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 06/01/2017 |
| West 5600 Healthcare LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/03/2026 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "How do you make sure resident assessments are completed and submitted to the state on time?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Mt Ogden Health and Rehabilitation Center | 4.2 mi | Washington Terrace, UT | ★★★★★ | 4/5 | |
| The Terrace Transitional | 4.2 mi | Ogden, UT | ★★★☆☆ | 2/5 | |
| Stonehenge of Ogden | 4.4 mi | Washington Terrace, UT | ★★★★★ | 4/5 | |
| South Ogden Post-Acute (cascades at South Ogden) | 5.2 mi | Ogden, UT | ★★☆☆☆ | 2/5 | |
| Rocky Mountain Care- Clearfield | 5.4 mi | Clearfield, UT | ★★☆☆☆ | 1/5 | |
| Thatcher Brook Rehabilitation & Care Center | 5.7 mi | Clearfield, UT | ★★★★★ | 3/5 | |
| Crestwood Rehabilitation and Nursing | 5.7 mi | Ogden, UT | ★★☆☆☆ | 1/5 | |
| Mountain View Health Services | 5.7 mi | Ogden, UT | —/5 | SFF | |
| Pine View Transitional Rehab | 5.8 mi | South Ogden, UT | ★★★★★ | 5/5 | |
| Harrison Pointe Healthcare and Rehabilitation | 5.9 mi | Ogden, UT | ★★★★☆ | 3/5 | |
| Fairfield Village Rehabilitation | 7.8 mi | Layton, UT | ★★★☆☆ | 2/5 | |
| George E. Wahlen Ogden Veterans Home | 8.2 mi | Ogden, UT | ★★★★☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 465003.