Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alpine Meadow Rehabilitation And Nursing during CMS and state inspections, most recent first.
Failure to document and act on pharmacy drug regimen review recommendations. For 5 residents, the pharmacist’s monthly consults identified medication irregularities, including PRN meds no longer used, a renal-related concern with milk of magnesia, elevated BP with lisinopril, and insulin timing issues. The recommendations were not documented on separate reports for physician review, and the MD did not document review of the irregularities or any action taken in the residents’ charts.
Failure to Evaluate Self-Administration of Nebulizer Medications: A resident with COPD and a history of recurrent pneumonia had a nebulizer machine and medication vials at the bedside and stated he administered the meds himself throughout the day. RN and DON stated no residents were self-administering meds, and no assessment was identified to determine whether self-administration was clinically appropriate and safe, despite facility policy requiring an interdisciplinary safety screen and provider orders.
A resident with heart failure, systolic CHF, and HTN had orders for metolazone 5 mg every 48 hours to be given 30 minutes prior to bumetanide 3 mg every 48 hours. Review of the MAR showed both diuretics were administered at the same time every 48 hours, and RN and DON interviews confirmed the medications should have been given 30 minutes apart.
Failure to Use EBP During Wound Care: A resident with an open wound and ordered daily wound treatment did not have EBP signage or PPE available outside the room, and an RN performed wound care using gloves and hand hygiene but no gown. The RN stated she did not think the resident needed EBP because the wound was healing, while the DON stated EBP should be used for residents with open wounds and that gown and gloves are required for high-contact care such as wound care.
Missing Influenza Vaccine Declination Documentation: A resident with neurocognitive disorder with Lewy bodies had no documentation in the MR for the current influenza season showing the vaccine was given, contraindicated, or refused. The RNC stated a spreadsheet indicated refusal, but no declination form was completed, and the facility reported offering COVID, flu, and pneumococcal vaccines during its seasonal immunization process.
A resident with neurocognitive disorder with Lewy bodies had no documentation in the medical record for the current COVID-19 season. The RNC stated the resident was listed as refusing the vaccine on a spreadsheet, but no declination form was completed, and the facility relied on admission consent forms and seasonal vaccine clinics to offer COVID, flu, and pneumococcal vaccines.
Staff, including a CNA and CNAC, were observed delivering and setting up meal trays for multiple residents without performing required hand hygiene before or after entering rooms or handling residents' items. Interviews with the CNAC and DON confirmed that hand hygiene is expected during these tasks, but observations showed repeated non-compliance, resulting in a deficiency in the facility's infection prevention and control program.
A resident with a history of diabetes and chronic kidney disease experienced a delay in treatment for a suspected UTI when lab results were not promptly obtained or reported to the provider. Although the urine sample was collected and showed signs of infection, there was a nine-day gap before the provider was notified and antibiotics were started. The DON acknowledged that the process for following up on lab results was not followed, leading to the delay in care.
Three residents in the facility experienced significant medication errors due to delayed insulin administration, with instances of insulin being administered hours past the scheduled times. Despite the facility's posted insulin administration schedule, the delays were frequent and substantial, affecting residents with diabetes and varying cognitive abilities. The ADON acknowledged the importance of timely insulin administration but the facility failed to comply with the prescribed times.
Two residents reported inappropriate touching by a CNA, with one resident having moderate cognitive impairment and the other having intact cognition. The facility's investigation lacked concrete evidence, and the CNA was suspended. The facility failed to report one of the allegations to the State Survey Agency as required.
A resident reported that a CNA brushed against her breast and patted her on the backside and stomach during care. The incident was not reported to the SSA within the required 24-hour timeframe, as it was included in another ongoing abuse investigation. The Administrator acknowledged the failure to report the allegation separately, resulting in a deficiency.
A facility failed to thoroughly investigate an abuse allegation involving a resident and a CNA. The resident reported that the CNA's hand brushed across their breast and they were patted on the backside and stomach, which was initially not reported as intentional. The incident was not independently investigated or reported to authorities, as it was included in another ongoing abuse investigation. Documentation was inadequate, lacking proper titles and dates.
Failure to Document and Act on Pharmacy Drug Regimen Review Recommendations
Penalty
Summary
The facility did not ensure that monthly pharmacist drug regimen review recommendations were acted upon or documented in the residents’ medical records for 5 of 20 sampled residents. The report identified residents 10, 18, 19, 24, and 34 as having pharmacy recommendations that were not documented on a separate report and sent to the attending physician or facility MD for review, and the MD did not document in the medical record that the irregularities had been reviewed or what action, if any, had been taken. The report also noted that if no medication change was ordered, the MD should document the rationale in the medical record. Resident 18 had diagnoses including dementia and paranoid schizophrenia. The pharmacy consult recommended changing Lantus and sliding scale Humalog so the resident would only be tested at dinner and bedtime, but the recommendation was not documented on a separate report for physician review and there was no MD documentation in the chart addressing the irregularity. Resident 24 had diagnoses including chronic venous hypertension with ulcer of the left lower extremity, schizoaffective disorder, and generalized anxiety disorder. Pharmacy consults recommended discontinuing milk of magnesia due to renal impairment, increasing lisinopril because blood pressure remained elevated, and discontinuing PRN Voltaren and Tums because they had not been used in over a month; these recommendations were not documented on a separate report for physician review, and the MD did not document review or action in the record. Resident 10 had diagnoses including major depressive disorder, PTSD, personality disorder, and generalized anxiety disorder. The pharmacy consult recommended discontinuing PRN lidocaine patches and albuterol because they had not been used in over a month; there was a handwritten note stating “0 DC per MD,” but the recommendation was not documented on a separate report for physician review and the MD did not document review or action in the medical record. Resident 19 had diagnoses including neurocognitive disorder with Lewy bodies, type 2 diabetes mellitus, dementia, major depressive disorder, generalized anxiety disorder, conversion disorder with seizures or convulsions, and cognitive communication deficit; the pharmacy consult recommended discontinuing several PRN medications that had not been used in over a month, but the recommendation was not documented on a separate report for physician review and the MD did not document review or action. Resident 34 had diagnoses including active primary progressive multiple sclerosis, major depressive disorder, and generalized anxiety disorder; pharmacy consults recommended discontinuing PRN guaifenesin and adding a schedule to PRN triamcinolone cream, but these recommendations were not documented on a separate report for physician review and the MD did not document review or action in the record.
Failure to Evaluate Self-Administration of Nebulizer Medications
Penalty
Summary
The facility did not ensure that a resident’s right to self-administer medications was clinically appropriate and safe. For 1 of 20 sampled residents, medication was observed in the resident’s room, but the resident had not been evaluated to determine whether self-administration was appropriate. The resident was observed with a nebulizer machine and three vials of medication on the nightstand, and stated that he administered the medication himself throughout the day. The resident was admitted and readmitted with diagnoses including acute and chronic respiratory failure with hypoxia, COPD, a personal history of recurrent pneumonia, and pneumonitis due to inhalation of food and vomit. During the observation, the resident stated that the vials contained nebulizer medication and that he used one vial after breakfast, before lunch, and before dinner. Review of the April 2026 MAR showed orders for albuterol sulfate inhalation solution every 4 hours as needed for shortness of breath and budesonide inhalation suspension twice daily for shortness of breath. Interviews with RN 1 and the DON indicated that the facility did not have residents self-administering medications and that no resident had requested to do so. The DON stated that if a resident requested self-administration, an assessment would be completed on admission and quarterly, and a lock box would be provided. The facility policy required an interdisciplinary assessment, documentation of the resident’s preference and safety screen, provider orders for self-administration, and appropriate bedside storage, but no evaluation was identified for this resident despite the medications being present in the room and the resident describing self-administration.
Medication Timing Error With Diuretics
Penalty
Summary
The facility did not ensure residents were free from significant medication errors for Resident 10, who was admitted and readmitted with diagnoses including heart failure, systolic congestive heart failure, and essential hypertension. A physician’s order dated 4/1/26 directed metolazone 5 mg by mouth every 48 hours for heart failure and specified to give it 30 minutes prior to Bumex (bumetanide), and another order dated 4/1/26 directed bumetanide 3 mg by mouth every 48 hours for heart failure. Review of the April 2026 MAR showed that metolazone and bumetanide were administered at the same time every 48 hours instead of 30 minutes apart. During interview, RN 1 stated the medications were given at the same time when they should have been administered 30 minutes apart per the physician’s order, and the DON confirmed the medications should have been given 30 minutes apart.
Failure to Use EBP During Wound Care
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. For 1 of 20 sampled residents, Resident 34, staff did not wear PPE during wound care for a resident who should have been on Enhanced Barrier Precautions (EBP). Resident 34 was admitted with an unspecified open wound of the lower back and pelvis, and a physician order dated 4/8/26 directed daily skin treatment to a chronic pilonidal ulcer, including cleansing, packing with a collagen sheet, and covering with a bordered dressing. During an observation on 4/20/26, RN 1 performed hand hygiene, donned gloves, removed the old bandage after the resident reported a bowel movement, cleaned the wound, and then completed packing and dressing changes while using gloves and hand hygiene but without gown use. RN 1 stated EBP would be used for any open wound and anything leaking, but also stated she did not think Resident 34 needed EBP because of the stage of the wound and because the wounds were healing. The DON stated that EBP should be implemented for residents with open wounds and that staff should wear PPE, including a gown and gloves, for high-contact activities such as wound care. The facility policy stated that residents with wounds requiring a dressing should have EBP, gowns and gloves should be available near or outside the room, and wound care is a high-contact activity requiring EBP.
Missing Influenza Vaccine Declination Documentation
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations. Based on interview and record review, the facility did not ensure that residents were offered the influenza vaccine and that the medical record included documentation that the resident either received the vaccine or did not due to medical contraindications or refusal. For Resident 19, who was admitted and later readmitted with diagnoses including neurocognitive disorder with Lewy bodies, the medical record showed the last influenza vaccine was completed on 10/25/24, but there was no documentation for the current 2025/2026 influenza season. During an interview, the Regional Nurse Consultant stated the facility did not have the requested documentation for Resident 19, noted that a spreadsheet indicated the resident refused, but no declination form was completed. The RNC also stated that immunization consent forms were included in admission paperwork and that the facility offered COVID, influenza, and pneumococcal vaccines in September and October and audited residents who were ready for an immunization clinic.
Failure to Document COVID-19 Vaccine Offer and Status
Penalty
Summary
The facility did not ensure residents were offered the COVID-19 vaccine and did not properly document vaccination status. For Resident 19, who was admitted and later readmitted with diagnoses including neurocognitive disorder with Lewy bodies, a review of the medical record showed no documentation for the current 2025/2026 COVID-19 season. During interview, the Regional Nurse Consultant stated the facility did not have the requested documentation for Resident 19, noted that a spreadsheet indicated the resident refused the vaccine, and stated that no declination form was completed. The RNC also stated that immunization consent forms were included in admission paperwork and that the facility offered COVID, influenza, and pneumococcal vaccines to residents in September and October, with audits and immunization clinics for residents who were ready.
Failure to Perform Hand Hygiene During Meal Tray Delivery
Penalty
Summary
The facility failed to establish and implement an effective infection prevention and control program, as evidenced by multiple instances where staff did not perform hand hygiene during meal tray delivery. Observations on several occasions showed that a Certified Nursing Assistant (CNA) and a Certified Nursing Assistant Coordinator (CNAC) delivered food trays to residents' rooms, set up meals, and handled residents' items without using hand sanitizer or washing hands before or after entering and exiting rooms. This included actions such as moving bedside tables, uncovering drinks, arranging meal items, and handling room curtains, all without performing hand hygiene between resident contacts. Interviews with the CNAC and the Director of Nursing (DON) confirmed that staff are expected to use hand sanitizer each time they enter or exit a resident's room and when handling meal trays or residents' items. Despite this expectation, direct observations revealed consistent non-compliance with hand hygiene protocols during meal service, contributing to the deficiency in the facility's infection prevention and control program.
Delay in Reporting Lab Results and Initiating Treatment for UTI
Penalty
Summary
A deficiency occurred when the facility failed to promptly obtain and report laboratory results for a resident who was experiencing urinary retention, dysuria, and other symptoms suggestive of a urinary tract infection. The resident, who had a history of generalized muscle weakness, type II diabetes, and chronic kidney disease stage 3, had a physician's order for a urinalysis and urine culture. The urine sample was collected and sent to the lab, and results indicating infection were available. However, there was a delay of nine days before the provider was notified of the results, during which time the resident continued to experience symptoms. Interviews with nursing staff and the DON revealed that the facility's process involved the lab faxing results to the facility, with nurses responsible for forwarding results to the provider. In this instance, the DON acknowledged that the final lab result was not received as expected and that she did not follow up with the lab until the provider inquired about the results. The delay resulted in the resident not receiving antibiotics until after the provider was made aware of the infection, despite the facility having access to an emergency kit containing antibiotics.
Significant Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure that three residents were free from significant medication errors, specifically in the administration of insulin. The residents involved were not given their insulin at the correct times as per physician orders, leading to multiple instances of delayed administration. The facility's posted insulin administration times were 7:00 AM, 11:30 AM, and 4:30 PM, but records showed that insulin was often administered late, sometimes by several hours. Resident 2, who had diagnoses including Type 1 and Type 2 diabetes mellitus, experienced multiple instances of late insulin administration. For example, on several occasions in May 2024, insulin was administered between 37 minutes to over two hours late. This resident had intact cognition, as indicated by a BIMS score of 14, and was aware of the delays in medication administration. Resident 4, with moderately impaired cognition and diagnoses including Type 2 diabetes mellitus with diabetic neuropathy, also experienced late insulin administration. The delays ranged from 44 minutes to over an hour. Similarly, Resident 10, who had intact cognition and multiple diagnoses including Type 2 diabetes mellitus with foot ulcer, experienced significant delays in insulin administration, with some instances being over four hours late. The Assistant Director of Nursing acknowledged the importance of administering insulin close to mealtimes and the potential implications of not doing so, yet the facility failed to adhere to the prescribed administration times.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, specifically inappropriate touching by a Certified Nurse Assistant (CNA). Resident 1, who has a moderate cognitive impairment, reported that a male CNA attempted to inappropriately touch her genitals during a brief change. Despite the resident's confusion about the timeline, she consistently reported feeling panicked and dazed by the incident. The facility's investigation could not verify the allegation due to the resident's cognitive state, but the CNA was suspended and eventually parted ways with the facility. Resident 11, who has intact cognition, reported that the same CNA inappropriately touched her by patting her bare buttocks during a brief change. She also mentioned that the CNA's hand brushed across her breast, which she initially thought was unintentional. The resident felt violated by the patting incident but did not report it immediately. The facility did not report this allegation to the State Survey Agency, which is a requirement for abuse allegations. The facility's investigation into these incidents involved interviews with staff and residents, but there was a lack of concrete evidence to substantiate the claims. The Administrator acknowledged the need to report abuse allegations to authorities within 24 hours, but this was not done for Resident 11's case. The CNA involved had no prior complaints, and the facility had conducted abuse and neglect training, which the CNA had completed.
Failure to Timely Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an alleged sexual abuse incident involving a resident within the required 24-hour timeframe to the State Survey Agency (SSA). The incident involved a resident who reported that a Certified Nursing Assistant (CNA) brushed against her breast and patted her on the backside and stomach while changing her. The resident initially did not think the actions were intentional and did not report them immediately. This information was later disclosed during an investigation of another abuse allegation. The Administrator confirmed that the incident was not reported as a separate abuse investigation. Instead, it was included in the ongoing investigation of another resident's abuse allegation. The Administrator acknowledged that all abuse allegations should be reported to authorities, including the local police department and ombudsman, within 24 hours. However, this specific allegation was not reported, resulting in a deficiency in the facility's compliance with reporting requirements.
Failure to Investigate Abuse Allegation Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident, identified as Resident 11. The incident involved a Certified Nurse Assistant (CNA 3) whose hand allegedly brushed across the resident's breast during a change, and the resident was also patted on the backside and stomach. The resident initially did not report the incident, believing it to be unintentional. However, the allegation surfaced during another abuse investigation. The documentation provided was untitled and undated, and it was attached to a form concerning another resident's abuse allegation, indicating a lack of proper documentation and investigation. The Administrator admitted that the incident was not reported or investigated as a separate abuse case. Instead, it was included in the ongoing investigation of another abuse allegation. The Administrator stated that the facility's protocol for abuse allegations involves gathering information from residents, staff, and witnesses, followed by a thorough five-day investigation. However, in this case, the facility did not adhere to these procedures, as the incident involving Resident 11 was not independently investigated or reported to authorities such as the local police department and ombudsman.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near West Valley City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Little Cottonwood Rehabilitation And Nursing | 2.8 mi | ★★★★★ | 5 | 0 |
| Rocky Mountain Care - Hunter Hollow | 2.9 mi | ★★★★★ | 19 | 0 |
| Pine Creek Rehabilitation And Nursing | 3.1 mi | ★★★★★ | 8 | 0 |
| Monument Healthcare South Salt Lake | 3.1 mi | ★★★★★ | 0 | 0 |
| Meadow Brook Rehabilitation And Nursing | 3.2 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.