Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Meadow Brook Rehabilitation and Nursing
Salt Lake City, UT · 41 certified beds · Last Life Safety survey November 20, 2025
CMS Certification Number 465158 · first certified May 2004
Ownership
Operated by CASCADES HEALTHCARE · Government - Hospital district
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within UT
6 citations — more than 57% of the 97 certified nursing homes in UT. Compared within UT rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 1.3. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens June 2027 — about 9 months from now. This facility’s last Life Safety survey was November 2025. Facilities in UT are typically surveyed 19–24 months after the last one (median 21), measured over 88 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
5 of the 6 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
7 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 6 Life Safety citations above. The Physical Environment Index
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0908 Keep all essential equipment working safely.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- F-0923 Have enough outside ventilation via a window or mechanical ventilation, or both.
How that compares
Compared with the median facility in UT, and nationally. Surveyors differ markedly between states, so the UT figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 6 |
| Median facility in UT | 3 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 25, 2022 | 1 |
| October 11, 2023 | 1 |
| February 22, 2024 | 2 |
| November 20, 2025 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 3 | 2025-11-20 |
| E-0039 | Conduct testing and exercise requirements. | 2 | 2025-11-20 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2023-10-11 |
What the citations cover
- Emergency Preparedness Deficiencies 5
- Miscellaneous Deficiencies 1
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 5 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 20, 2025 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (December 15, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (December 15, 2025) |
February 22, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (March 29, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (March 29, 2024) |
October 11, 2023 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 6, 2023) |
May 25, 2022 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (June 16, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.