Nursing Care Index

Msm Brigham City LLC

Brigham City, Box Elder County, Utah · CCN 465165 · For-profit (LLC) · part of Mission Health Services (7 facilities, chain average 3.4 stars)

CMS rates Msm Brigham City LLC 3 of 5 overall as of August 2026. 41 certified beds, 40 residents a day on average. 47 citations on record from the current inspection cycles, 2 at immediate jeopardy; 2 fines totalling $67,436 and 1 payment denial.

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★★★☆☆ 3 of 5
Health inspections★★☆☆☆ 2 of 5
Staffing★★★★☆ 4 of 5
Quality measures★★★★★ 5 of 5
Quality: long-stay / short-stay5 / 5 of 5

Staffing

Total nurse staffing4.16431 hours per resident per day
Registered nurses1.19315 hours per resident per day
Weekend total4.15547 hours per resident per day
Nursing staff turnover60% (registered nurses 52.9%)
Administrators who left0

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2025-12-15 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · tag F0690
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2025-12-31
2025-12-15 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2026-01-12
2025-12-15 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.
Pharmacy Service Deficiencies · tag F0761
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-12-31
2025-12-15 Keep complete, dated laboratory records in the resident's record.
Administration Deficiencies · tag F0775
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-12-31
2025-12-15 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.
Nutrition and Dietary Deficiencies · tag F0801
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-12-31
2025-12-15 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies · tag F0804
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2026-01-16
2025-12-15 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · tag F0842
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-12-31
2025-12-15 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-01-16
2025-12-15 Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights Deficiencies · tag F0628
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-31
2025-12-15 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-01-13
2025-12-15 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2026-01-16
2025-12-15 Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Administration Deficiencies · tag F0773
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-31
2025-12-15 Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
Administration Deficiencies · tag F0779
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-12-31
2023-12-18
complaint survey
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-01-18
2023-12-18 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-01-18
2023-12-18 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.
Pharmacy Service Deficiencies · tag F0761
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-01-18
2023-12-18 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-01-18
2023-12-18
complaint survey
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-01-18
2023-12-18 Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies · tag F0554
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-01-18
2023-12-18 Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-01-18
2023-12-18
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-01-18
2023-12-18 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · tag F0755
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-01-18
2023-12-18 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies · tag F0756
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-01-18
2023-12-18 Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · tag F0757
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-01-18
2023-12-18 Provide timely, quality laboratory services/tests to meet the needs of residents.
Administration Deficiencies · tag F0770
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-01-18
2023-12-18 Implement a program that monitors antibiotic use.
Infection Control Deficiencies · tag F0881
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-01-18
2022-03-02 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
L Immediate jeopardy to resident health or safety; widespread Deficient, Provider has date of correction
2022-04-15
2022-03-02 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600
J Immediate jeopardy to resident health or safety; isolated Deficient, Provider has date of correction
2022-04-15
2022-03-02 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0603
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2022-04-15
2022-03-02 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2022-04-15
2022-03-02 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.
Resident Rights Deficiencies · tag F0585
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-04-15
2022-03-02 Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0607
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-04-15
2022-03-02 Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · tag F0759
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-04-15
2022-03-02 Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Administration Deficiencies · tag F0835
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-04-15
2022-03-02 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies · tag F0867
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-04-15
2022-03-02 Ensure staff are vaccinated for COVID-19
Infection Control Deficiencies · tag F0888
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2022-04-15
2022-03-02 Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies · tag F0554
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-15
2022-03-02 Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Resident Rights Deficiencies · tag F0561
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-15
2022-03-02 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies · tag F0580
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-15
2022-03-02 Keep residents' personal and medical records private and confidential.
Resident Rights Deficiencies · tag F0583
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-15
2022-03-02 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-15
2022-03-02 Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-15
2022-03-02 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.
Resident Rights Deficiencies · tag F0622
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-15
2022-03-02 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-15
2022-03-02 Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Nursing and Physician Services Deficiencies · tag F0729
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-15
2022-03-02 Provide medically-related social services to help each resident achieve the highest possible quality of life.
Quality of Life and Care Deficiencies · tag F0745
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-15
2022-03-02 Provide or get specialized rehabilitative services as required for a resident.
Quality of Life and Care Deficiencies · tag F0825
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2022-04-15

Fines and payment denials

DatePenaltyAmount
2025-12-15Fine$26,871
2023-12-18Payment denial for 32 days from 2024-01-06
2023-12-18Fine$40,565

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Msm Brigham City
Organization
adp of the snf2026-02-27
Path Accounting LLC
Organization
adp of the snf2025-04-01
Msm Brigham City
Organization
operational/managerial control2023-07-01
Dunn, Marc
Individual
adp of the snf2019-02-01
Larsen, Nicholas
Individual
adp of the snf2019-02-01
Larsen, Ryan
Individual
adp of the snf2025-04-01
Rawls, Danielle
Individual
adp of the snf2025-04-01
Andersen, Jeanette
Individual
corporate director2016-01-01
Anderson, Steve
Individual
corporate director2015-01-01
Bartholomew, Lamar
Individual
corporate director2014-07-01
Blackham, Brady
Individual
corporate director2020-07-01
Dyreng, Casey
Individual
corporate director2018-01-01
Pickett, Kim
Individual
corporate director2015-01-01
Sorenson, Merri Lynn
Individual
corporate director2018-05-31
Bartholomew, Brenda
Individual
corporate officer2021-10-01
Murray, Brian
Individual
corporate officer2014-05-01
Larsen, Ryan
Individual
managing control - governing body2025-04-01
Rawls, Danielle
Individual
managing control - governing body2025-04-01
Dunn, Marc
Individual
operational/managerial control2023-07-01
Larsen, Nicholas
Individual
operational/managerial control2023-07-01
Larsen, Ryan
Individual
operational/managerial control2025-04-01
Rawls, Danielle
Individual
operational/managerial control2025-04-01

What changed

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Box Elder County.