Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Pointe Meadows Health And Rehabilitation during CMS and state inspections, most recent first.
The facility did not consistently disinfect glucose monitors between resident uses and failed to implement Enhanced Barrier Precautions for a resident with a PICC line, despite physician orders and care plan directives. Staff demonstrated inconsistent understanding and application of infection control protocols, and necessary PPE and signage were not present for residents requiring EBP.
Two residents experienced deficiencies in care when a medication was left unattended at a bedside without proper authorization or assessment, and a tube feed bag was found unlabeled and undated. Staff interviews confirmed that both actions were not in line with professional standards, as medications should only be left at bedside with a physician's order and assessment, and tube feeds must be labeled with date and time.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a deficiency related to the delivery of individualized care.
Two residents with complex medical conditions had laboratory tests ordered, but the results were not filed in their clinical records. Staff interviews revealed that issues with the online lab portal and differences in handling STAT versus routine labs contributed to the missing documentation, as results were not consistently uploaded to the residents' medical records.
A resident with multiple chronic conditions did not have documentation in their medical record indicating whether the pneumococcal vaccine was offered, received, refused, or medically contraindicated. Staff interviews confirmed that while vaccines are supposed to be offered and documented at admission, this process was not followed for the resident, resulting in a lack of required immunization documentation.
Surveyors found that drugs and biologicals, specifically insulin products for two residents, were not labeled or stored according to professional standards. An LPN and the DON confirmed that opened insulin should be dated and used within 28 days, and unopened insulin should be refrigerated, but surveyors observed opened and unopened insulin stored improperly in a medication cart instead of a refrigerator.
Failure to Implement Infection Control Measures and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in the cleaning and disinfection of glucose monitors and the implementation of Enhanced Barrier Precautions (EBP) for residents with specific medical needs. Observations revealed that an LPN did not disinfect the glucose monitor between uses for several residents, despite facility policy and CDC recommendations requiring disinfection after each use. The LPN was seen using the glucose monitor on multiple residents without cleaning it in between, and only wiped it down after several uses, contrary to the stated procedures. Interviews with staff indicated inconsistent understanding and practices regarding the appropriate cleaning agents and methods for disinfecting glucose monitors between residents. Additionally, the facility did not implement EBP for a resident with a peripherally inserted central catheter (PICC) line, despite physician orders and care plan interventions specifying the need for such precautions. Observations showed that there was no EBP signage or personal protective equipment (PPE) available at the resident's room, and a nurse accessed the resident's PICC line without wearing a gown. Interviews with staff revealed confusion about which residents required EBP and how these precautions should be communicated and implemented, with some staff relying solely on the presence of signage to determine precaution requirements. The residents involved included individuals with complex medical conditions, such as a resident with a psoas muscle abscess, cognitive communication deficit, and neuromuscular dysfunction of the bladder, who was receiving intravenous antibiotics through a PICC line. The lack of proper infection control measures and inconsistent application of EBP and disinfection protocols contributed to the facility's failure to provide a safe and sanitary environment and to prevent the transmission of communicable diseases and infections.
Failure to Meet Professional Standards in Medication Management and Tube Feed Labeling
Penalty
Summary
Two deficiencies were identified in the facility's provision of care as outlined by the comprehensive care plan. For one resident with chronic respiratory failure, COPD, and cognitive communication deficit, Fluticasone-Salmeterol Inhalation Aerosol Powder was observed left unattended on the bedside table. The resident reported that staff typically removed the medication after use but sometimes forgot to do so. Review of the medical record confirmed the medication was to be administered twice daily, and interviews with nursing staff and the Director of Nursing confirmed that medications should not be left at the bedside unless there is a physician's order and a self-administration assessment has been completed. No such order or assessment was documented for this resident. In a separate incident, another resident with a history of nontraumatic intracranial hemorrhage, aphasia, quadriplegia, and hydrocephalus was observed with an unlabeled and undated tube feed bag. The resident was on a continuous enteral feeding regimen, and staff interviews confirmed that all tube feeds should be labeled with the date, time started, and the nurse's initials. The Director of Nursing also stated that tube feed bags and tubing should be replaced every 24 hours and labeled accordingly. The lack of labeling on the tube feed bag was not in accordance with these professional standards.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Maintain Complete Laboratory Records in Resident Files
Penalty
Summary
The facility failed to maintain complete, dated laboratory records in the clinical records of two residents. For one resident with diagnoses including acute respiratory failure with hypoxia, Crohn's disease, and hemiplegia, multiple physician orders for laboratory tests such as Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and Clostridioides difficile (C-diff) were documented, but the corresponding laboratory results were not found in the resident's medical record. Nursing progress notes and physician orders confirmed that these labs were ordered and should have been completed, yet no results were available in the record during the review period. For another resident with schizoaffective disorder, diabetes mellitus with kidney complication, and chronic kidney disease, an active physician's order for Glycated Hemoglobin (HgbA1C) to be drawn every six months was present, but no laboratory results were located in the medical record. Interviews with staff revealed that STAT lab results were typically faxed and reviewed by the provider, while routine labs were accessed through an online portal and were supposed to be uploaded to the resident's medical record by medical records staff. However, issues with the online portal and differences in how STAT and routine labs were managed led to missing documentation of lab results in the residents' records.
Failure to Document and Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that each resident was offered the pneumococcal vaccine and that proper documentation was maintained in the medical record. Specifically, for one sampled resident with chronic diastolic heart failure, emphysema, and unspecified dementia, there was no documentation indicating whether the pneumococcal vaccine was offered, received, refused, or medically contraindicated. Review of the resident's admission immunization record revealed that none of the options regarding the pneumococcal vaccine were marked, and there was no evidence in the medical record of the resident's immunization history or that the vaccine had been offered. Interviews with nursing staff and the Infection Preventionist confirmed that the process for offering and documenting vaccines relied on forms completed at admission and follow-up by the Infection Preventionist. However, in this case, the required documentation was missing from the resident's record. Staff stated that vaccines, including pneumococcal, were to be offered and documented upon admission, but this was not completed for the resident in question.
Improper Labeling and Storage of Insulin Products
Penalty
Summary
Surveyors observed that the facility failed to ensure drugs and biologicals were labeled and stored according to accepted professional principles. Specifically, during an inspection of a medication cart, an opened vial of insulin lispro for one resident was found with an open date, and staff stated it was still within the 30-day usage period. However, both the LPN and DON later clarified that insulin should be used within 28 days of opening and must be dated accordingly. Additionally, three unopened insulin auto injector pens, including a Humalog kwikpen labeled for refrigeration, were found stored in the medication cart instead of the medication refrigerator. The LPN confirmed that unopened insulin should be refrigerated and that extra supplies would typically be stored in the medication fridge. Interviews with staff, including two LPNs and the DON, revealed inconsistent understanding and application of insulin storage and labeling protocols. The DON confirmed that unopened insulin should be refrigerated and that opened insulin should be dated and used within 28 days. The observed deficiencies involved two residents, one of whom was a type 1 diabetic using an insulin pump and requiring frequent blood glucose monitoring. The improper storage and labeling of insulin products were directly observed and verified by staff during the survey.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Neurorestorative | 5.7 mi | ★★★★★ | 0 | 0 |
| Monument Healthcare American Fork | 6.1 mi | ★★★★★ | 7 | 0 |
| Draper Rehabilitation And Care Center | 6.6 mi | ★★★★★ | 4 | 0 |
| Stonehenge Of American Fork | 6.8 mi | ★★★★★ | 0 | 0 |
| Rocky Mountain Care - Riverton | 7.7 mi | ★★★★★ | 0 | 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.