Salt Lake Behavioral Health
A psychiatric hospital in Salt Lake City, Utah 84106
3802 South 700 East, Salt Lake City, Utah 84106. (801) 264-6000.
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The short answer
Record last released by CMS on Oct 20, 2026.
- Not rated CMS’s overall rating
- Not rated patient survey rating
- 1 deficiency cited in the last three years
- 118 beds
Each figure’s source sits beside it, in its section below.
What these words mean2
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Apr 1, 2026: a complaint inspection.
1 deficiency cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
1 deficiency in 1 month of the last 36. Last cited Apr 2026. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Apr 1, 2026: complaint inspection1 deficiency
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Supervision Of Contract Staff
The inspectors’ words, 648 words
“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 38303 Based on interview and record review, it was determined the hospital did not ensure that for 1 of the 4 sampled patients, a nurse adhered to the policies and procedures of the hospital. Specifically, the nurse did not recheck or report a blood pressure below 100/60 and proceeded to administer medication to lower blood pressure. (Patient identifier: 1) Findings Include: On December 1, 2025, Patient 1 was admitted to the hospital for rehabilitation treatment related to the diagnosis of alcohol use disorder. The surveyor completed a review of Patient 1 ’ s medical record on April 1, 2026 and the following was documented by hospital staff: On December 23, 2025, at 7:25 AM Nurse 1 recorded Patient 1 ’ s blood pressure as 85/54 in the observation notes. This same reading of 85/54 was documented again two minutes later at 7:27 AM. On December 23, 2025, at 7:27 AM the medication administration record (MAR) indicated 12.5 milligrams of Metoprolol, a medication used to treat high blood pressure, was administered to Patient 1 by Nurse 1. The surveyor reviewed the facility ’ s vital signs policy. The policy indicated that when vital sign findings were abnormal, or there was a change in the patient ’ s vital signs, the patient ’ s vital signs should be repeated manually after having the patient sit for 5 minutes of rest. Staff then report any abnormal vital signs to the unit nurse and provider. The unit nurse must then co-sign the abnormal values on the vital signs flow sheet. The abnormal vital signs parameters for blood pressure were defined as systolic BP less than 100 or greater than 150, and/or diastolic BP less than 60 or greater than 90. Note: Blood pressure is measured with two numbers. The systolic number is the top number, and indicates the pressure in the arteries when the heart beats. The diastolic number is the bottom number, and indicates the pressure in the arteries when the heart is at rest. When either of these numbers is too low, there may not be enough pressure to supply oxygen and nutrients to the body. On March 25, 2026, the surveyor interviewed Nurse 1 regarding the vital signs procedures, and documented administration of the medication Metoprolol to Patient 1 on December 23, 2025 at 7:27 AM with a BP of 85/54. Nurse 1 acknowledged that a BP of 85/54 was abnormal. The nurse acknowledged that the tech took the vital signs and that he likely did not verify the BP before administering the medication to Patient 1. He was aware that abnormal vital signs should be rechecked and reported to a medical provider. He stated that he would have held the medication Metoprolol if he had noticed Patient 1 had a diastolic BP of less than 60. On April 1, 2026, the surveyor interviewed the hospital ’ s Chief Executive Officer (CEO), who acknowledged that the hospital’s policy required nursing staff to report abnormal vital signs to the medical provider and that the on-call provider should have been called regarding Patient 1 ’ s abnormal blood pressure on December 23, 2025. On April 1, 2026, the surveyor interviewed Physician 1, who acknowledged that they were the physician treating Patient 1 at the time of the low BP reading on December 23, 2026. He did not recall if a technician or nurse discussed the low BP measurement with him directly.”
All 3 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Apr 1, 2026 | Complaint inspection | 1 deficiency cited |
| Aug 6, 2025 | Complaint inspection | No deficiencies cited |
| May 9, 2024 | Complaint inspection | No deficiencies cited |
How do patients fare?
- CMS gives no overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “Data are shown only for hospitals that participate in the Inpatient Quality Reporting (IQR) and Outpatient Quality Reporting (OQR) programs.”
- CMS publishes no patient survey results for it.
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | Not rated |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | Not rated |
Is it certified, and in good standing?
- Medicare-certified psychiatric hospital since Mar 17, 2011.
- Ownership: proprietary.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- Proprietary.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- CMS’s HAC Reduction Program file has no result for it: the program covers general acute care hospitals Medicare pays under its inpatient prospective payment system.
- 1 deficiency cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Ascend Health Corporation owns 100% directly since Jul 26, 2010.
- Uhs of Delaware Inc. runs it.
- 18 owners or officers are people: Daren K Woolstenhulme (managing employee (under contract), 100%); Daren K Woolstenhulme (corporate officer, 100%); George H Brunner (corporate officer, 100%); Katharine M Lyver (corporate officer, 100%); Matthew D Klein (corporate officer, 100%); Matthew J Peterson (corporate officer, 100%); Matthew J Peterson (runs it (operational or managerial control), 100%); Thomas M Day (corporate officer, 100%); Steve Filton (corporate officer, 100%); Steve Filton (runs it (operational or managerial control), 100%); Cheryl K Ramagano (corporate officer, 100%); Alan B Miller (owns 5% or more through other companies, 87.4%); James M Coleman (managing employee (under contract), 50%); Matthew J Peterson (corporate director, 33.3%); Thomas M Day (corporate director, 33.3%); Steve Filton (corporate director, 33.3%); Dustin Gallegos (managing employee (under contract), 0%); Dustin Gallegos (corporate officer, 0%).
- CMS’s Provider of Services file records 1 change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Universal Health Services Inc. | Owns 5% or more through other companies | 100% | Jun 2, 2000 |
| Ascend Health Corporation | Owns 5% or more directly | 100% | Jul 26, 2010 |
| Uhs of Delaware Inc. | Runs it (operational or managerial control) | Jun 2, 2000 |
How does it compare nearby?
- Of the 13 hospitals CMS lists in Salt Lake County, 10 have an overall star rating from CMS: 6 rated 5 of 5, 3 rated 4 of 5, 1 rated 3 of 5.
- CMS gives this hospital no overall star rating to compare.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.