Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 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.
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 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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What surveyors actually found near you
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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 July 2026) and official state health department websites.