Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Pointe Meadows Health and Rehabilitation

Lehi, UT · 99 certified beds · Last Life Safety survey August 7, 2025

CMS Certification Number 465188 · first certified October 2017

Ownership

Operated by THE ENSIGN GROUP · For profit - Corporation

  • Ownership changed January 2, 2019 (change of ownership)from POINTE MEADOW HEALTHCARE INC
8
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
0
Tags cited more than once
Across separate surveys
1
Inspection & testing records
Of the citations on file

Position within UT

8 citations — more than 68% of the 97 certified nursing homes in UT. Compared within UT rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 0 citations; the earlier surveys in the window averaged 4. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens March 2027 — about 5 months from now. This facility’s last Life Safety survey was August 2025. Facilities in UT are typically surveyed 19–24 months after the last one (median 21), measured over 88 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

Emergency preparedness

4 of the 8 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 8 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0584 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.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in UT, and nationally. Surveyors differ markedly between states, so the UT figure is the meaningful one.

This facility8UT median3National median11
Citations on file over three years, compared
MeasureCitations
This facility8
Median facility in UT3
Median facility nationally11

Survey history

Citations at each Life Safety survey
72022-0412023-1102025-08
Citations at each Life Safety survey
Survey dateCitations
April 7, 20227
November 16, 20231
August 7, 20250

Most-cited tags

Most-cited tags at this facility
E-00361K-03631E-00041K-02221E-00391K-09211K-09201E-00371
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
E-0036Establish emergency prep training and testing.12022-04-07
K-0363Install corridor and hallway doors that block smoke.12022-04-07
E-0004Develop and maintain an Emergency Preparedness Program (EP).12022-04-07
K-0222Add 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.12022-04-07
E-0039Conduct testing and exercise requirements.12022-04-07
K-0921Ensure that testing and maintenance of electrical equipment is performed.12023-11-16
K-0920Ensure proper usage of power strips and extension cords.12022-04-07
E-0037Establish staff and initial training requirements.12022-04-07

What the citations cover

Citations by CMS category
  • Emergency Preparedness Deficiencies 4
  • Gas, Vacuum, and Electrical Systems Deficiencies 2
  • Egress Deficiencies 1
  • Smoke Deficiencies 1
Citations by CMS category
CategoryCitations
Emergency Preparedness Deficiencies4
Gas, Vacuum, and Electrical Systems Deficiencies2
Egress Deficiencies1
Smoke Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

November 16, 2023 — 1 citation

Citations issued on November 16, 2023
TagWhat the surveyor checksStatus
K-0921Ensure that testing and maintenance of electrical equipment is performed.Deficient, Provider has date of correction (January 15, 2024)

April 7, 2022 — 7 citations

Citations issued on April 7, 2022
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (June 1, 2022)
E-0036Establish emergency prep training and testing.Deficient, Provider has date of correction (June 1, 2022)
E-0037Establish staff and initial training requirements.Deficient, Provider has date of correction (June 1, 2022)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (June 1, 2022)
K-0222Add 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.Deficient, Provider has date of correction (June 1, 2022)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (June 1, 2022)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (June 1, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.