MSM Brigham City LLC
Open-data reference.
MSM Brigham City LLC is a for profit - limited liability company facility in Brigham City, UT with 41 certified beds and a 3-star overall CMS rating. The facility has 40 deficiency records on file. Total penalties: $41K.
1010 South Medical Drive, Brigham City, UT 84302
Phone: 4353105800
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 465165
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 41
- Residents
- 38
- In Hospital
- No
- County
- Box Elder
- Last Inspection
- Dec 15, 2025
Staffing Data
- RN Hours
- 1.17 (nat'l avg: 0.68)
- LPN Hours
- 0.06
- CNA Hours
- 2.83
- Total Nursing Hours
- 4.06 (nat'l avg: 3.89)
- PT Hours
- 0.15
- Nursing Turnover
- 62.5%
- RN Turnover
- 63.6%
What the CMS Record Reveals About MSM Brigham City LLC
MSM Brigham City LLC operates 41 certified beds in Brigham City, UT with approximately 38 residents currently in care, and carries a CMS overall rating of 3 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (4★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 40 deficiency records from recent surveys, of which 4 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $41K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 4.06 total nursing hours per resident day (national average 3.89), with RN coverage at 1.17 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, MSM Brigham City LLC falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 62.5%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (40 most recent)
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jan 18, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 18, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jan 18, 2024
Implement a program that monitors antibiotic use.
Category: Infection Control Deficiencies
Corrected: Jan 18, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jan 18, 2024
Provide timely, quality laboratory services/tests to meet the needs of residents.
Category: Administration Deficiencies
Corrected: Jan 18, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Jan 18, 2024
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: Jan 18, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Jan 18, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Jan 18, 2024
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jan 18, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jan 18, 2024
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Jan 18, 2024
Ensure staff are vaccinated for COVID-19
Category: Infection Control Deficiencies
Corrected: Apr 15, 2022
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 15, 2022
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: Apr 15, 2022
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Category: Administration Deficiencies
Corrected: Apr 15, 2022
Provide or get specialized rehabilitative services as required for a resident.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 15, 2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 15, 2022
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Apr 15, 2022
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 15, 2022
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 15, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 15, 2022
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.
Category: Resident Rights Deficiencies
Corrected: Apr 15, 2022
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 15, 2022
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 15, 2022
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 15, 2022
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 15, 2022
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Apr 15, 2022
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.
Category: Resident Rights Deficiencies
Corrected: Apr 15, 2022
Keep residents' personal and medical records private and confidential.
Category: Resident Rights Deficiencies
Corrected: Apr 15, 2022
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Apr 15, 2022
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Category: Resident Rights Deficiencies
Corrected: Apr 15, 2022
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Apr 15, 2022
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Category: Administration Deficiencies
Corrected: Feb 26, 2020
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 26, 2020
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.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 26, 2020
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Category: Pharmacy Service Deficiencies
Corrected: Feb 26, 2020
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Category: Nursing and Physician Services Deficiencies
Corrected: Feb 26, 2020
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 26, 2020
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 7.7% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 12.2% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.2% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 3.8% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 96.5% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 95.7% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.7% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 11.1% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 29.7% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 92.2% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 3.1% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 29.7% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 12.9% | Yes |
Penalty History 1 penalties totaling $41K
| Date | Type | Amount |
|---|---|---|
| Dec 18, 2023 | Fine | $41K |
| Dec 18, 2023 | Payment Denial | - |
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County Health Data
Health outcomes, access, and quality metrics for Box Elder on PlainHealth
Frequently Asked Questions
What is the overall CMS rating for MSM Brigham City LLC?
What are the staffing levels at MSM Brigham City LLC?
How many beds does MSM Brigham City LLC have?
Does MSM Brigham City LLC have any deficiencies on record?
Has MSM Brigham City LLC received any fines or penalties?
Who owns MSM Brigham City LLC?
When was MSM Brigham City LLC last inspected?
What quality measures are tracked for MSM Brigham City LLC?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.