St Joseph Villa

Name: St Joseph Villa
Address: 451 East Bishop Federal Lane, Salt Lake City, UT, 84115, US
Telephone: 8014877557

451 East Bishop Federal Lane, Salt Lake City, UT 84115 · Salt Lake County · 221 certified beds · avg 172 residents/day · certified since Oct 1, 1984

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.33

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · 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 16, 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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Oct 23, 2023 (Past Non-Compliance)

▲ Actual harm, one-off · Sep 1, 2022 · F-0686

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

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: Oct 17, 2022 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Sep 1, 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: Sep 1, 2022 (Past Non-Compliance)

All citations in the current public record (14)

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 16, 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. · from a complaint
Jul 16, 2024	E · Potential for harm, repeated	The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. · from a complaint
Jul 16, 2024	E · Potential for harm, repeated	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Jul 16, 2024	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Jul 16, 2024	D · Potential for harm, one-off	The facility did not provide routine dental care and 24-hour emergency dental care for residents. · from a complaint
Jul 16, 2024	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. · from a complaint
Sep 1, 2022	▲ G · Actual harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Sep 1, 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.
Sep 1, 2022	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Sep 1, 2022	D · Potential for harm, one-off	The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Mar 4, 2020	E · Potential for harm, repeated	The facility did not keep residents' personal and medical information private and confidential.
Mar 4, 2020	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.
Mar 4, 2020	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.
Mar 4, 2020	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.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (4 → 5).

Year	Citations	Serious (G–L)	Worst severity that year
2020	4	0	E
2022	4	2	G ▲
2024	6	1	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)

No fines or payment denials in the published 3-year window.

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)	3.33	3.87	3.95	bottom 30% in Utah; bottom 28% in the U.S.
Registered Nurse hours	0.95	1.17	0.69	bottom 44% in Utah; top 18% in the U.S.
Weekend total nurse staffing	2.92	3.39	3.50	bottom 32% in Utah; bottom 27% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.60	0.88	0.48	bottom 30% in Utah; top 23% in the U.S.
Total nursing staff turnover (%)	31.2	50.7	45.8	top 7% in Utah; top 17% in the U.S.
RN turnover (%)	18.2	40.6	42.9	top 13% in Utah; top 12% 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 3.59, RN 1.02, weekend 3.15. Staffing rating: 4/5.

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: 4/5 · long-stay residents: 2/5 · short-stay residents: 5/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Albrechtsen, Brad	Individual	Managing Control - Governing Body	NOT APPLICABLE	02/01/2011
Albrechtsen, Brad	Individual	Operational/Managerial Control	NOT APPLICABLE	02/01/2011
Albrechtsen, Brad	Individual	ADP of the SNF	NOT APPLICABLE	02/01/2011
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	02/01/2011
Caretrust GP LLC	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2016
Caretrust Reit INC	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2016
Ctr Partnership LP	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2016
Davidson, Craig	Individual	Corporate Officer	NOT APPLICABLE	06/20/1990
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	12/08/2010
Gangotena-Bernard, Fatima	Individual	Managing Control - Governing Body	NOT APPLICABLE	12/26/2024
Gangotena-Bernard, Fatima	Individual	Operational/Managerial Control	NOT APPLICABLE	12/26/2024
Gangotena-Bernard, Fatima	Individual	ADP of the SNF	NOT APPLICABLE	12/26/2024
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	03/01/2011
Mission CCRC LLC	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2016
Moss, Tyler	Individual	Corporate Officer	NOT APPLICABLE	08/01/2015
Successor Healthcare LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	05/01/2016
Successor Healthcare LLC	Organization	ADP of the SNF	NOT APPLICABLE	09/16/2025

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 prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
"Do you have a qualified dietician on staff, and how involved are they in each resident's nutrition plan?"
"How do you keep residents' medical records accurate, complete, and secure?"
"How do residents get routine dental care, and what happens if someone has a dental emergency at night?"
"When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
"If my family member is able to manage their own medications, would you allow it, and how is that decided?"
"What is your policy on physical restraints, and what alternatives do you try first?"
"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	0.8 mi	Salt Lake City, UT	★☆☆☆☆	1/5	SFF
Meadow Brook Rehabilitation and Nursing	1.1 mi	Salt Lake City, UT	★★☆☆☆	1/5	abuse
Little Cottonwood Rehabilitation and Nursing	1.8 mi	South Salt Lake, UT	★★★★★	5/5
Millcreek Rehabilitation and Nursing	2.0 mi	Salt Lake City, UT	★★☆☆☆	1/5	abuse
Maple Ridge Rehabilitation and Nursing	2.2 mi	Salt Lake City, UT	★☆☆☆☆	2/5	abuse
Pine Creek Rehabilitation and Nursing	2.4 mi	Salt Lake City, UT	★★★☆☆	2/5	abuse
City Creek Post Acute	2.5 mi	Salt Lake City, UT	★★★☆☆	3/5
Monument Healthcare Murray Creek	2.8 mi	Millcreek, UT	★★☆☆☆	1/5	abuse
Paramount Health and Rehabilitation	3.0 mi	Salt Lake City, UT	★★★☆☆	2/5
William E Christofferson Salt Lake Veterans Home	3.2 mi	Salt Lake City, UT	★★★★★	4/5
Alpine Meadow Rehabilitation and Nursing	3.3 mi	West Valley City, UT	★★★☆☆	2/5
Mt. Olympus Rehabilitation Center	3.3 mi	Salt Lake City, UT	★★☆☆☆	1/5

Compare this facility with the 3 closest →

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Facility data as of CMS processing date 2026-08-01. CCN 465095.

The Care File

Visit checklist — St Joseph Villa

451 East Bishop Federal Lane, Salt Lake City, UT 84115 · 8014877557

Health inspection rating 3/5 · CMS overall 3/5· Fines (3y): $0

Most serious findings on record:

▲ Jul 16, 2024 (F-0689, 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.
▲ Sep 1, 2022 (F-0686, Actual harm, one-off): The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
▲ Sep 1, 2022 (F-0689, 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.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
☐ "Do you have a qualified dietician on staff, and how involved are they in each resident's nutrition plan?"
☐ "How do you keep residents' medical records accurate, complete, and secure?"
☐ "How do residents get routine dental care, and what happens if someone has a dental emergency at night?"
☐ "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
☐ "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
☐ "What is your policy on physical restraints, and what alternatives do you try first?"
☐ "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?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 465095 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)