01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-12-15 | 13 | 2025-12-15 | 7 |
| Cycle 2 | 2023-12-18 | 13 | 2023-12-18 | 5 |
| Cycle 3 | 2022-03-02 | 21 | 2022-03-02 | 2 |
CMS CCN 4651652026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Msm Brigham City Llc
1010 South Medical Drive · Brigham City, UT 84302 · Box Elder County
Certified beds41CMS provider file
Recent citation rows61current CMS citation release
Penalty rows3current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
61 rows in the current release
5 rows carry G–L scope/severity codes; 2 carry J–L. 13 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-12-15 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-01-162025-12-15 · HEALTHF0628Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2025-12-312025-12-15 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2026-01-132025-12-15 · HEALTHF0690Severity G · isolated actual harm
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.
Correction field: Deficient, Provider has date of correction · 2025-12-312025-12-15 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2026-01-162025-12-15 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-12-312025-12-15 · HEALTHF0773Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Correction field: Deficient, Provider has date of correction · 2025-12-312025-12-15 · HEALTHF0775Severity E · pattern; potential for more than minimal harm
Administration Deficiencies
Keep complete, dated laboratory records in the resident's record.
Correction field: Deficient, Provider has date of correction · 2025-12-312025-12-15 · HEALTHF0779Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Keep signed and dated reports of x-rays and other diagnostic services in the residents record.
Correction field: Deficient, Provider has date of correction · 2025-12-312025-12-15 · HEALTHF0801Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-12-312025-12-15 · HEALTHF0804Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2026-01-162025-12-15 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-01-122025-12-15 · HEALTHF0842Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-12-312025-12-15 · FIREK0211Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2025-12-312025-12-15 · FIREK0291Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2025-12-312025-12-15 · FIREK0321Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-12-312025-12-15 · FIREK0711Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Correction field: Deficient, Provider has date of correction · 2025-12-312025-12-15 · FIREK0918Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-12-312025-12-15 · FIREK0920Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2025-12-312025-12-15 · FIREK0921Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure that testing and maintenance of electrical equipment is performed.
Correction field: Deficient, Provider has date of correction · 2025-12-312023-12-18 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2024-01-182023-12-18 · HEALTHF0600Severity G · isolated actual harm
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.
Correction field: Deficient, Provider has date of correction · 2024-01-18 · complaint2023-12-18 · HEALTHF0609Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2024-01-182023-12-18 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2024-01-1803 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-12-15 | Fine | $26,871 | 0 |
| 2023-12-18 | Fine | $40,565 | 0 |
| 2023-12-18 | Payment Denial | $0 | 32 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- LARSEN, RYANIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2025
- RAWLS, DANIELLEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/01/2025
- ANDERSEN, JEANETTEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2016
- ANDERSON, STEVEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2015
- BARTHOLOMEW, LAMARIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2014
- BLACKHAM, BRADYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2020
- DYRENG, CASEYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2018
- PICKETT, KIMIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2015
- SORENSON, MERRI LYNNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/31/2018
- BARTHOLOMEW, BRENDAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 10/01/2021
- MURRAY, BRIANIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/01/2014
- MSM BRIGHAM CITYOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2023
- DUNN, MARCIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2023
- LARSEN, NICHOLASIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2023
- LARSEN, RYANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2025
- RAWLS, DANIELLEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2025
- MSM BRIGHAM CITYOrganization · ADP OF THE SNFNOT APPLICABLE · since 02/27/2026
- PATH ACCOUNTING LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 04/01/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.16per resident day
RN hours1.19per resident day
Weekend nurse hours4.16per resident day
Staff turnover60.0%CMS reported field
06 / LOCAL RECORDS
Open the Brigham City ledger →