Meadow Brook Rehabilitation and Nursing
433 East 2700 South, Salt Lake City, UT 84115 · Salt Lake County · 41 certified beds · avg 27 residents/day · certified since May 17, 2004
Abuse citation flag (CMS)
Part of chain: CASCADES HEALTHCARE (19 facilities, chain avg rating 1.9★)
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: ★☆☆☆☆1/5 · CMS overall rating: 2/5
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)
▲ Immediate jeopardy, one-off · Feb 22, 2024 · F-0689 · triggered by a complaint
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 (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 19, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Feb 22, 2024 · F-0726 · triggered by a complaint
The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Why it matters: Undertrained caregivers are more likely to miss warning signs and make care mistakes.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 19, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Feb 22, 2024 · F-0867 · triggered by a complaint
The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Why it matters: Without a working quality program, the same care problems tend to repeat instead of getting fixed.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Apr 19, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 22, 2024 · F-0578 · triggered by a complaint
The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Why it matters: Ignoring these rights means residents may receive treatments they refused, or miss having their end-of-life wishes respected.
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: Apr 19, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 22, 2024 · F-0624 · triggered by a complaint
The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly.
Why it matters: An unprepared discharge can send a resident somewhere unsafe or without the care arrangements they need.
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: Apr 19, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 22, 2024 · F-0690 · triggered by a complaint
The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Why it matters: Poor continence and catheter care leads to infections, skin breakdown, and loss of dignity.
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: Apr 19, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 22, 2024 · F-0697 · triggered by a complaint
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
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: Apr 19, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 22, 2024 · F-0740 · triggered by a complaint
The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.
Why it matters: A resident's untreated mental health needs can worsen and take a toll on their physical health too.
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: Apr 19, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (59)
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 |
|---|---|---|
| Nov 20, 2025 | F · Potential for harm, facility-wide | 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. |
| Nov 20, 2025 | 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. |
| Nov 20, 2025 | E · Potential for harm, repeated | The facility did not keep complete, dated laboratory records in residents' files. |
| Nov 20, 2025 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Nov 20, 2025 | E · Potential for harm, repeated | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. · from a complaint |
| Nov 20, 2025 | 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. · from a complaint |
| Nov 20, 2025 | D · Potential for harm, one-off | 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. |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them. |
| Nov 20, 2025 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Oct 24, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 22, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 22, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Feb 22, 2024 | ▲ H · Actual harm, repeated | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint |
| Feb 22, 2024 | ▲ G · Actual harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint |
| Feb 22, 2024 | ▲ G · Actual harm, one-off | The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly. · from a complaint |
| Feb 22, 2024 | ▲ G · Actual harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Feb 22, 2024 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Feb 22, 2024 | ▲ G · Actual harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint |
| Feb 22, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. · from a complaint |
| Feb 22, 2024 | 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. · from a complaint |
| Feb 22, 2024 | E · Potential for harm, repeated | 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 |
| Feb 22, 2024 | E · Potential for harm, repeated | 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. · from a complaint |
| Feb 22, 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. · from a complaint |
| Feb 22, 2024 | 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 |
| Feb 22, 2024 | E · Potential for harm, repeated | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. · from a complaint |
| Feb 22, 2024 | E · Potential for harm, repeated | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint |
| Feb 22, 2024 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Feb 22, 2024 | E · Potential for harm, repeated | The facility did not make sure its nurse aides were properly trained — aides working more than 4 months must be trained and competent, and newer aides must be enrolled in training. · from a complaint |
| Feb 22, 2024 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint |
| Feb 22, 2024 | E · Potential for harm, repeated | 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. · from a complaint |
| Feb 22, 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. · from a complaint |
| Feb 22, 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. · from a complaint |
| Feb 22, 2024 | E · Potential for harm, repeated | 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. · from a complaint |
| Feb 22, 2024 | E · Potential for harm, repeated | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. · from a complaint |
| Feb 22, 2024 | E · Potential for harm, repeated | The facility did not have enough fresh-air ventilation, whether through windows, mechanical systems, or both. · from a complaint |
| Feb 22, 2024 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. · from a complaint |
| Feb 22, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Feb 22, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Feb 22, 2024 | 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. · from a complaint |
| Feb 22, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Feb 22, 2024 | D · Potential for harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint |
| Feb 22, 2024 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · from a complaint |
| Feb 22, 2024 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. · from a complaint |
| Feb 22, 2024 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Feb 22, 2024 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. · from a complaint |
| Feb 22, 2024 | 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. · from a complaint |
| Feb 22, 2024 | D · Potential for harm, one-off | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint |
| Feb 22, 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. · from a complaint |
| Feb 22, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Feb 22, 2024 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. · from a complaint |
| Feb 22, 2024 | D · Potential for harm, one-off | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · from a complaint |
| Feb 22, 2024 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
| May 25, 2022 | 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. |
| May 25, 2022 | 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. |
| May 25, 2022 | 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. |
| May 25, 2022 | 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. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (42 → 12).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 4 | 0 | E |
| 2024 | 43 | 8 | J ▲ |
| 2025 | 12 | 0 | F |
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 $31,331, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Feb 22, 2024 | Fine | $31,331 |
| Feb 22, 2024 | Payment Denial | 6 days from Apr 13, 2024 |
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) | 3.75 | 3.87 | 3.95 | top 37% in Utah; bottom 49% in the U.S. |
| Registered Nurse hours | 1.42 | 1.17 | 0.69 | top 21% in Utah; top 6% in the U.S. |
| Weekend total nurse staffing | 3.05 | 3.39 | 3.50 | bottom 40% in Utah; bottom 33% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.90 | 0.88 | 0.48 | top 38% in Utah; top 8% in the U.S. |
| Total nursing staff turnover (%) | 77.8 | 50.7 | 45.8 | bottom 2% in Utah; bottom 3% in the U.S. |
| RN turnover (%) | 71.4 | 40.6 | 42.9 | bottom 8% in Utah; bottom 11% 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 3.81, RN 1.44, weekend 3.10. 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: 5/5 · short-stay residents: —/5
Who owns this facility
Government - Hospital district
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Baird, Gregory | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2023 |
| Baird, Gregory | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2023 |
| Barney, Janett | Individual | Corporate Director | NOT APPLICABLE | 09/18/2018 |
| Brown, Gary | Individual | Corporate Director | NOT APPLICABLE | 09/18/2018 |
| Cascades Healthcare LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2023 |
| Cascades Healthcare LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/17/2025 |
| Hills, Kyle | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/28/2025 |
| Hills, Kyle | Individual | ADP of the SNF | NOT APPLICABLE | 09/05/2025 |
| Langford, Scott | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/18/2018 |
| Langford, Scott | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2014 |
| McSpadden, Darin | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2023 |
| McSpadden, Darin | Individual | Corporate Officer | NOT APPLICABLE | 04/01/2014 |
| McSpadden, Darin | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2014 |
| McSpadden, Darin | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 10/23/2025 |
| McSpadden, Darin | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2023 |
| Oakden, Richard | Individual | Corporate Director | NOT APPLICABLE | 09/18/2018 |
| Robinson, Matthew | Individual | Corporate Director | NOT APPLICABLE | 09/18/2018 |
| Smith, Val | Individual | Corporate Director | NOT APPLICABLE | 09/18/2018 |
| White, Craig | Individual | Corporate Director | NOT APPLICABLE | 09/18/2018 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "What does your discharge planning process look like, and how are families involved before a move?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "What mental health services do you provide on-site, and who delivers them?"
- "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 |
|---|---|---|---|---|---|
| Monument Healthcare South Salt Lake | 0.3 mi | Salt Lake City, UT | ★☆☆☆☆ | 1/5 | SFF |
| Little Cottonwood Rehabilitation and Nursing | 0.8 mi | South Salt Lake, UT | ★★★★★ | 5/5 | |
| St Joseph Villa | 1.1 mi | Salt Lake City, UT | ★★★☆☆ | 3/5 | |
| Millcreek Rehabilitation and Nursing | 1.6 mi | Salt Lake City, UT | ★★☆☆☆ | 1/5 | abuse |
| Monument Healthcare Murray Creek | 1.8 mi | Millcreek, UT | ★★☆☆☆ | 1/5 | abuse |
| Paramount Health and Rehabilitation | 2.0 mi | Salt Lake City, UT | ★★★☆☆ | 2/5 | |
| Mt. Olympus Rehabilitation Center | 2.8 mi | Salt Lake City, UT | ★★☆☆☆ | 1/5 | |
| Monument Healthcare Millcreek | 2.9 mi | Salt Lake City, UT | ★★★★☆ | 3/5 | |
| Alpine Meadow Rehabilitation and Nursing | 3.2 mi | West Valley City, UT | ★★★☆☆ | 2/5 | |
| Highland Care Center | 3.2 mi | Holladay, UT | ★★★★★ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 465158.