Cycle 1
Health 2025-08-07 · Fire 2025-08-07
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lehi, UT
Pointe Meadows Health and Rehabilitation
5-star overall rating with 4-star inspections with 6 recent health deficiencies
2750 North Digital Drive, Lehi, UT
(385) 374-5600
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
84
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2017-10-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.94
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.87
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.70
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.32
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.75
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.27
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
3.72
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,914
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.06
Composite VBP score used to determine payment impact.
Payment multiplier
1.0077
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.93
Baseline 18.09% · Performance 18.68% · Measure score 5.93 · Achievement 5.93 · Improvement 0
Healthcare-associated infections
10
Baseline 4.45% · Performance 4.67% · Measure score 10 · Achievement 10 · Improvement 0
Total nurse turnover
3.35
Baseline 65.14% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 3.26
Adjusted total nurse staffing
1.95
Baseline 3.81 hours · Performance 3.63 hours · Measure score 1.95 · Achievement 1.95 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.26% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 300 · Observed rate 8.67% · Lower 95% interval 7.88% |
| Discharge to community | 76.03% |
50.57%
25.5 pts better
|
Better than the National Rate · Eligible stays 268 · Observed rate 77.99% · Lower 95% interval 70.38% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 140 · Denominator 140 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 140 |
| Discharge self-care score | 47.32% |
53.69%
6.4 pts worse
|
Numerator 53 · Denominator 112 |
| Discharge mobility score | 55.36% |
50.94%
4.4 pts better
|
Numerator 62 · Denominator 112 |
| Pressure ulcers or injuries, new or worsened | 0.71% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 140 · Adjusted rate 1.07% |
| Healthcare-associated infections requiring hospitalization | 4.67% |
7.12%
2.5 pts better
|
No Different than the National Rate · Eligible stays 142 · Observed rate 0.7% · Lower 95% interval 2.45% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 190 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 52.68% |
56.45%
3.8 pts worse
|
Numerator 59 · Denominator 112 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 96 · Denominator 96 |
| Transfer of health information to patient | 96.55% |
96.28%
0.3 pts better
|
Numerator 28 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 32.39% |
25.2%
7.2 pts better
|
Numerator 23 · Denominator 71 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.4 |
1.2
0.8 pts better
|
1.9
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.5 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.4% |
96.8%
2.4 pts worse
|
93.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 89.8% · Q2 96.2% · Q3 95.9% · Q4 95.7% · 4Q avg 94.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.4% |
98.0%
6.6 pts worse
|
95.5%
4.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.6% |
2.6%
3 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 5.7% · Q3 6.1% · Q4 2.1% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.6% |
16.1%
7.5 pts better
|
11.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 5.8% · Q3 14.3% · Q4 8.5% · 4Q avg 8.6% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
3.8%
1.6 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 0.0% · Q4 4.8% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.7% |
24.1%
9.4 pts better
|
19.6%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 14.6% · Q3 10.9% · Q4 16.3% · 4Q avg 14.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.9% |
15.4%
13.5 pts better
|
16.7%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 2.4% · Q4 2.6% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.5% |
0.1%
0.4 pts worse
|
0.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.8% |
18.3%
8.5 pts worse
|
16.3%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.6% |
13.6%
2 pts better
|
14.9%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 11.1% · Q3 4.7% · Q4 17.1% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.1% |
1.8%
2.3 pts worse
|
1.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 4.2% · Q4 10.9% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.6% |
22.4%
3.2 pts worse
|
19.8%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.0% · Q2 29.1% · Q3 24.4% · Q4 27.4% · 4Q avg 25.6% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
4.1%
1.1 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.0% · Q3 3.1% · Q4 2.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
93.3%
2.5 pts better
|
81.7%
14.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 95.6% · Q3 95.3% · Q4 93.7% · 4Q avg 95.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.0% |
11.8%
2.8 pts better
|
12.0%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.0% · Observed 8.9% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.1% |
0.9%
0.8 pts better
|
1.6%
1.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.4% |
91.0%
13.6 pts worse
|
79.7%
2.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.9% |
17.4%
2.5 pts worse
|
23.9%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 16.1% · Expected 19.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-16 · Fire 2023-11-16
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-04-07 · Fire 2022-04-07
10 health deficiencies
Top issue: Infection Control (2 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-11-16
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-01-15
F · Potential for more than minimal harm
2022-04-07
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2022-06-01
F · Potential for more than minimal harm
2022-04-07
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-06-01
F · Potential for more than minimal harm
2022-04-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-06-01
F · Potential for more than minimal harm
2022-04-07
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-07
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-06-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-08-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-08-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-08-07
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-08-07
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-08-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-09-08
F · Potential for more than minimal harm
2023-11-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-11-16
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-11-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-11-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-11-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-11-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-04
E · Potential for more than minimal harm
2022-04-07
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-06-01
E · Potential for more than minimal harm
2022-04-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-01
E · Potential for more than minimal harm
2022-04-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-06-01
E · Potential for more than minimal harm
2022-04-07
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-07
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-04-07
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2022-06-01
Penalties and ownership
What sits behind the stars
Ownership
Beaver Valley Hospital
5% Or Greater Direct Ownership Interest · Organization
Brown, Zachary
Operational/Managerial Control · Individual
Brown, Zachary
W-2 Managing Employee · Individual
Burnam, Soon
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Davidson, Craig
Corporate Director · Individual
Davidson, Craig
Corporate Officer · Individual
Pointe Meadow Healthcare Inc
Operational/Managerial Control · Organization
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#3
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4-star overall rating with 4-star inspections with 4 recent health deficiencies
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