Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Harrison Pointe Healthcare And Rehabilitation during CMS and state inspections, most recent first.
Dish machine wash temperatures were repeatedly observed below the manufacturer-required minimum of 120 degrees Fahrenheit, while trays, plates, bases, and domes were washed and then put away with clean dishes. The DM signed the temperature log as 120 degrees for wash and rinse despite surveyor observations showing lower wash temps, and the DM stated the machine sometimes did not work and that a contractor was working on the washing machines.
Infection prevention and control failed when a resident with a surgical wound and external fixator did not have EBP signage or PPE available, and an RN performed wound care without maintaining a clean field, changing gloves, or performing hand hygiene between dirty and clean tasks. The RN also handled clean supplies with bare hands and left contaminated supplies in the room. In separate events, an LPN touched the medication cart and computer equipment, then administered medications and performed a blood sugar check for two residents without hand hygiene before or after care.
Unwarranted Wander Guard Placement: A resident with dementia, intermittent confusion, and no documented wandering or exit-seeking behavior was placed in a wander guard after a fall and during a UTI episode. Records repeatedly identified the resident as low wander risk with no elopement history, and MDS notes stated she did not wander. Staff later described her as ambulatory and not exit seeking, yet the wander guard remained on and the resident asked for it to be removed.
Tube Feeding Labeling and Documentation Deficiencies: Two residents had tube feeding formula containers that were not labeled with all required information. One resident’s enteral feed was observed infusing as the wrong formula compared with the order, and staff could not clearly verify when the formula was changed. Another resident’s tube feeding label was incomplete, with staff and the DON describing expected labeling elements that were not fully present on the observed container.
A resident with COPD, asthma, and OSA had a BiPAP machine at the bedside but could not use it because a needed oxygen adapter was missing. The record had no physician order, progress note, or care plan for the BiPAP, and staff said they were unaware the resident had the machine or that it needed to be set up for use.
Two residents in the facility did not receive their morning medications within the scheduled time frame. One resident, with a history of cerebral infarction and other health issues, received medications late due to the RN's interruptions and lack of assistance. Another resident, with chronic obstructive pulmonary disease and atrial fibrillation, also received medications late, despite the facility's flex med pass policy. The DON confirmed no assistance was requested, and expected documentation for late administration was not completed.
A resident identified as a high elopement risk did not receive adequate supervision or interventions, leading to an elopement incident. Despite assessments indicating high wander risk, the care plan lacked necessary precautions until after the resident eloped. The DON confirmed that appropriate measures were not in place, and documentation of wander precautions was absent.
Dish Machine Wash Temperature Below Manufacturer Requirement
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety because the dish machine was not consistently reaching the manufacturer-required wash temperature of 120 degrees Fahrenheit. During observation, the dish machine wash cycle was repeatedly documented below the required temperature, including readings of 110, 105, 105, and between 105 and 110 degrees Fahrenheit, while the rinse temperature was observed at 117 to 124 degrees Fahrenheit. Plates, bases, trays, and domes were observed being washed during these cycles and then put away with the clean dishes by the Dietary Manager. The dish machine temperature log was reviewed and showed the Dietary Manager signed that the wash and rinse temperatures were 120 degrees Fahrenheit for breakfast on 3/4/26, despite the lower temperatures observed by surveyors. The Dietary Manager stated he had checked the machine earlier that morning and that the temperatures were 120, but also stated the machine sometimes did not work and he used a digital thermometer that had the same reading. The Dietary Manager said he was going to get the Maintenance Director to look at the dish machine. The Administrator stated the facility had a contractor working on the washing machines, which was probably why the dish machine temperatures were lower.
Infection Prevention and Control Program Failure
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment. For a resident with a surgical wound and an external fixator, Enhanced Barrier Precautions (EBP) were ordered, but no EBP notification or signage was posted outside the room and no PPE was available inside or immediately outside the room. During wound care, the RN placed a chuck on the floor to serve as the wound care surface, removed soiled dressings, and continued the treatment without donning EBP PPE beyond gloves. Hand hygiene was not performed between dirty and clean tasks, and contaminated gloves were used while moving from one wound site to another and while handling clean supplies. During the same wound care treatment, the RN removed and reapplied dressings on the resident’s lower extremity and external fixation device while continuing to use the same contaminated gloves. The RN was observed opening gauze packets and cutting gauze with bare hands, then later using new gloves to continue the dressing change. The Maintenance Director entered the room and stepped over the wound supply field while the treatment was in progress. Used supplies were gathered and thrown into the trash can inside the resident’s room, and contaminated supplies were left in the room when the RN exited. The facility also failed to maintain hand hygiene during medication administration and blood sugar monitoring for two other residents. An LPN touched the computer keyboard, mouse, medication cart, and cart keys, then prepared and administered medications without performing hand hygiene. The LPN performed a blood sugar check on one resident after donning gloves without hand hygiene and removed the gloves without performing hand hygiene afterward. The LPN again touched the cart and computer equipment before preparing medications for another resident and administered the medications without hand hygiene, including after taking back a medication cup from the resident. The DON stated that staff should wash their hands during medication pass and between patients, and that hand sanitizer should be available on the medication cart and in the hallway.
Unwarranted Wander Guard Placement
Penalty
Summary
The facility did not treat a resident with respect and dignity when it placed a wander guard on a resident who had no documented exit-seeking behavior. Resident 32 was admitted with diagnoses including unspecified dementia without behavior disturbance, metabolic encephalopathy, and mild cognitive impairment. An elopement/wandering assessment completed on 11/28/25 documented the resident as a low wander risk with no elopement history and alert and oriented status. A nurse practitioner/physician assistant note on 12/19/25 documented that the resident had no hallucinations, delusions, violent behavior, verbal threats, screaming behavior, or attempts to wander out of the facility. After a fall on 1/26/26, a nursing note documented that the resident had a small bruise to the right temple area, was being treated with antibiotics for a UTI, had baseline confusion, and that a wander guard was placed on the left ankle to prevent exiting the facility due to wandering around and forgetting her walker. The note also stated the husband and MD were aware of the fall and ankle guard. On 1/29/26, another nursing note documented increased confusion while the resident was being treated for a UTI with a Foley catheter. On 1/31/26, the resident asked to have the wander guard removed, and staff told her it needed to stay on because she was still a little confused due to the UTI; she agreed to keep it on. The antibiotic for the UTI was completed on 2/1/26, and a care plan focus was initiated that day for elopement risk/wandering related to impaired cognition and wandering. However, the record noted that the resident had no documented wandering behavior. A later MDS note on 2/23/26 stated that she does not wander and does not reject cares, and a quarterly MDS on 2/27/26 showed a BIMS score of 10. A repeat elopement/wandering assessment on 3/1/26 again documented the resident as a low wander risk with no elopement history and intermittent confusion. During an interview on 3/2/26, the resident appeared excited and asked if the wander guard would be removed, while the nurse stated it had to stay on. Staff interviews on 3/2/26, 3/3/26, and 3/4/26 described the resident as intermittently confused, ambulatory, not exit seeking, and without a history of wandering except for one episode when she walked by the nurses station and out the front door during the UTI.
Tube Feeding Labeling and Documentation Deficiencies
Penalty
Summary
The facility did not ensure that tube feeding services met professional standards of quality for 2 of 29 sampled residents. For Resident 4, who was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, COPD, protein-calorie malnutrition, and dysphagia, an observation on 3/1/26 at 10:27 AM showed Jevity 1.2 infusing with a handwritten date of 3/1/26 at 0940 on the formula container. The resident’s family member stated the resident was supposed to receive a Two Cal formula for weight gain and that the tube feeding ran for 14 hours during the day. A physician’s order dated 2/25/26 directed a Two Cal enteral feed at 90 ml/hr for 14 hours, starting at 0500 and stopping at 2000. During an interview later that day, RN 1 stated she knew the resident’s tube feeding was supposed to be Two Cal instead of Jevity 1.2 and said she changed it, but she was not sure what time she changed the formula. She also stated she did not hang the Jevity 1.2 formula and that it should have been started at 5:00 AM. The Jevity 1.2 was observed infusing at 10:27 AM, and the Two Cal was not infusing at that time even though it was documented as started at 8:00 AM. On 3/3/26, RN 2 observed the tube feeding with only a date and time written on it and no other written information. For Resident 44, who was admitted with diagnoses including dysphagia and protein-calorie malnutrition, an observation on 3/1/26 at 12:13 PM showed tube feeding formula labeled only with “14 a 3/1” while the pump was set at a continuous rate of 45 ml/hr. On 3/3/26 at 6:52 AM, the tube feeding formula was labeled “14 A 3/3/26 0445.” A physician’s order dated 2/13/26 directed Jevity 1.2 at 45 ml/hr for 24 hours with water flushes every 4 hours. RN 2 stated she would change and discard old feeding supplies daily and that she would label the tube feeding formula with the date, time, room number, patient’s name, signature of the nurse, name of formula, and dose; she also stated the water bag should include the date, time, patient’s name, nurse signature, and water rate. The DON stated the tube feeding formula was already labeled and that she would expect the nurse to write the date, time, and room number on the tube feeding formula.
BiPAP Machine Not Supported by Orders or Proper Setup
Penalty
Summary
Safe and appropriate respiratory care was not provided for a resident with COPD, asthma, and obstructive sleep apnea who had a BiPAP machine at the bedside but could not use it because a needed adapter was missing. The resident stated he had been using oxygen for about a month, had not used the BiPAP since admission, and preferred to use the BiPAP while sleeping instead of oxygen. He reported that he had ordered the adapter from the VA but had not received it, and he stated the BiPAP machine was missing the special adapter needed to connect oxygen. The resident’s record did not contain progress notes, physician orders, or a care plan documenting the BiPAP machine, and an inventory of personal effects did not include the BiPAP machine. During interviews, an RN stated she was not aware the resident had a BiPAP machine, while an LPN stated that if a resident was admitted with or needed a BiPAP machine, she would ensure there was a physician order and diagnosis. The ADON stated the resident had admitted from home without orders for the BiPAP machine and that the facility did not know he had one, while the RNC stated that if the resident had a diagnosis they would usually try to set the resident up with something.
Delayed Medication Administration for Two Residents
Penalty
Summary
The facility failed to ensure that two residents received their morning medications within the scheduled time frame, as per professional standards of practice and the comprehensive person-centered care plan. Resident 12, who has a history of cerebral infarction, chronic respiratory failure, and other significant health issues, was observed receiving their morning medications at 10:40 AM, despite the physician's orders indicating they were due between 7:00 AM and 9:00 AM. The RN responsible for administering the medications admitted to being late due to interruptions and did not seek assistance, even though the facility's system indicated that the medications were overdue. Similarly, Resident 13, diagnosed with chronic obstructive pulmonary disease and atrial fibrillation, received their medications at 11:09 AM, beyond the scheduled time frame of 7:00 AM to 9:00 AM. The LPN administering the medications acknowledged the delay and mentioned the facility's flex med pass policy, which allows for a one-hour window before and after the scheduled time. However, the medications were still administered outside this window. The DON confirmed the flex policy and stated that no requests for assistance were made by the nursing staff, and expected documentation and provider notification for late medication administration were not completed.
Failure to Implement Elopement Precautions for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and interventions for a resident identified as a high elopement risk. The resident, who was admitted with diagnoses including dementia and cognitive communication deficit, underwent an elopement assessment upon admission, which identified them as a high wander risk. Despite this assessment, the resident's care plan was not updated to include wander risk and elopement prevention interventions. A subsequent assessment confirmed the resident's high wander risk, noting behaviors such as disorientation, exit-seeking, and a history of elopement, yet still, no interventions were added to the care plan. The deficiency became evident when the resident eloped from the facility, crossing a local street before being redirected back by staff. This incident occurred four days after the second elopement assessment, during which time no additional supervision or interventions had been implemented. The Director of Nursing acknowledged that appropriate measures, such as one-on-one supervision and door alarms, were not in place, and there was no documentation to show that wander precautions were implemented after the assessments. The care plan was only updated after the elopement incident occurred.
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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 Ogden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crestwood Rehabilitation And Nursing | 0.3 mi | ★★★★★ | 4 | 0 |
| Stonehenge Of Ogden | 1.7 mi | ★★★★★ | 0 | 0 |
| Mt Ogden Health And Rehabilitation Center | 2.6 mi | ★★★★★ | 0 | 0 |
| The Terrace Transitional | 2.6 mi | ★★★★★ | 0 | 0 |
| South Ogden Post-acute (cascades At South Ogden) | 2.7 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.