Deficiencies (last 3 years)
Deficiencies (over 3 years)
16.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
111% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Oct 21, 2024
Visit Reason
The inspection was conducted due to allegations of sexual abuse and concerns about resident safety, capacity to consent, and supervision in a nursing home memory care unit.
Complaint Details
The complaint investigation involved allegations of sexual abuse between residents in the memory care unit, failure to protect residents from abuse, neglect, and exploitation, failure to report abuse timely, inadequate supervision leading to elopements, and medication and care deficiencies.
Findings
The facility failed to protect residents from sexual abuse by other residents, did not ensure timely reporting of suspected abuse, failed to provide adequate supervision to prevent elopements, did not provide appropriate respiratory care orders, did not provide timely pain management, did not ensure pharmaceutical services met residents' needs, and did not maintain food service areas according to professional standards.
Deficiencies (7)
Failure to protect residents from sexual abuse and ensure capacity to consent for relationships among residents.
Failure to timely report suspected abuse and neglect to proper authorities.
Failure to provide adequate supervision to prevent resident elopements from memory care unit.
Failure to ensure resident had physician orders specifying oxygen delivery system, administration times, and settings.
Failure to provide timely and effective pain management for resident with chronic mouth pain.
Failure to provide routine and emergency pharmaceutical services; resident administered own medications brought by family without proper documentation or physician notification.
Failure to maintain food service areas in accordance with professional standards; steam table soiled, dusty hood vents, soiled wall behind dish machine, missing grout, and dusty fan.
Report Facts
Residents affected by sexual abuse: 7
BIMS scores: 10
BIMS scores: 0
Medication doses missed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Administered medications to resident 160 without proper documentation; failed to document medication refusal and did not verify medications brought by family. |
| RN 1 | Registered Nurse | Described medication administration procedures and reporting requirements for family-administered medications. |
| DON | Director of Nursing | Provided multiple interviews regarding abuse investigations, medication policies, resident supervision, and capacity to consent assessments. |
| DM | Dietary Manager | Interviewed regarding kitchen cleanliness and maintenance issues. |
| RN 3 | Registered Nurse | Described oxygen therapy assessment and administration practices. |
| LPN 4 | Licensed Practical Nurse | Described medication refill and emergency medication system procedures. |
| RNC | Regional Nurse Consultant | Interviewed regarding medication administration and family involvement. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 21, 2024
Visit Reason
The inspection was conducted due to allegations of sexual abuse and inadequate supervision of residents with cognitive impairments, including incidents of inappropriate sexual behavior and elopement from the facility.
Complaint Details
The complaint involved allegations of sexual abuse between residents 310 and 311, and between residents 409 and 209. Investigations revealed multiple incidents of inappropriate sexual behavior, some reported as non-consensual. The allegations were not substantiated as abuse but identified as residents lacking capacity to consent. Additionally, residents 50 and 70 eloped from the facility, raising concerns about supervision.
Findings
The facility failed to protect residents from sexual abuse by other residents, did not adequately assess residents' capacity to consent to relationships, and failed to provide adequate supervision to prevent elopement. Multiple incidents involving residents 50, 70, 208, 209, 310, 311, and 409 were documented, including sexual abuse allegations and elopement events.
Deficiencies (2)
Failure to protect residents from all types of abuse including sexual abuse by other residents.
Failure to ensure adequate supervision to prevent accidents and elopement of residents with cognitive impairment.
Report Facts
Residents sampled: 69
Residents affected: 7
Fall risk assessment score: 9
BIMS score: 1
BIMS score: 0
BIMS score: 10
BIMS score: 99
BIMS score: 0
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 19
Date: Jan 30, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements and investigate complaints.
Findings
The facility was found deficient in multiple areas including resident neglect, failure to provide timely pain management, inadequate care planning, unsafe environment leading to falls and injuries, improper use of restraints, failure to maintain infection control protocols, medication errors, and failure to monitor antibiotic use. Several residents experienced harm due to these deficiencies.
Deficiencies (19)
Failure to honor residents' rights to dignified existence and care, including untreated pain and lack of clean clothes for residents 22 and 47.
Failure to ensure residents' rights to formulate advance directives, with missing code status documentation for resident 298.
Failure to maintain confidentiality of residents' medical records, with exposed computer screens and paperwork.
Failure to maintain a safe, clean, and comfortable environment, including dirty wheelchairs, disrepair of walls and furniture, and unclean IV poles and nightstands.
Failure to protect residents from neglect, including lack of assistance with activities of daily living, untreated pain, weight loss, falls with injuries, and wounds for residents 22, 27, 33, 47, 146, 244, and 298.
Failure to ensure residents' drug regimens are free from unnecessary drugs, including resident 20 on prolonged prophylactic antibiotic therapy without adequate indication.
Failure to provide safe and appropriate respiratory care, including resident 298 not placed on supplemental oxygen on admission and lacking physician orders for oxygen.
Failure to provide safe and appropriate pain management, including residents 22 and 298 not receiving timely pain relief medication.
Failure to ensure residents are free from physical restraints imposed for convenience and not medical necessity, including improper use and monitoring of mittens and bed rails for residents 82 and 146.
Failure to timely report and investigate suspected abuse, including an allegation of staff hitting resident 33 that was not reported to the State Survey Agency or investigated.
Failure to ensure necessary information is communicated to the resident and receiving health care provider at discharge, including missing discharge summary for resident 93.
Failure to ensure residents do not lose ability to perform activities of daily living, including lack of feeding assistance and cueing for resident 244.
Failure to provide care and assistance to perform activities of daily living, including lack of toileting and bathing assistance for residents 27, 60, 295, and 349.
Failure to provide appropriate treatment and care according to orders and resident preferences, including delayed wound care and lack of investigation for penile wound for resident 244.
Failure to maintain a safe environment and provide adequate supervision to prevent accidents, including a fall resulting in eye laceration for resident 146, and lack of fall prevention interventions for residents 27 and 41.
Failure to provide appropriate care for residents who are continent or incontinent of bowel/bladder, including inadequate catheter care for resident 295 resulting in hospitalization for UTI.
Failure to ensure feeding tubes are not used unless medically necessary and provide appropriate care, including multiple observations of a dirty nasal gastric feeding tube for resident 39.
Failure to ensure drugs and biologicals are labeled and stored according to professional principles, including leaving medications unattended on medication carts.
Failure to provide and implement an infection prevention and control program, including improper use of PPE, cross contamination during wound care and medication pass, unclean equipment, and failure to follow isolation precautions for residents 21, 27, 50, 82, 244, and 295.
Report Facts
Sample residents: 54
Medication opportunities observed: 30
Medication errors observed: 2
Weight loss percentage: 5.5
Weight loss percentage: 12.4
Weight loss percentage: 7.4
Medication duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 6 | Licensed Practical Nurse | Named in pain management and medication pass findings related to resident 22 |
| LPN 8 | Licensed Practical Nurse | Named in abuse allegation reporting related to resident 33 |
| CNA 10 | Certified Nursing Assistant | Named in abuse allegation related to resident 33 |
| DON | Director of Nursing | Named in multiple findings including pain management, infection control, and quality assurance |
| ADON 1 | Assistant Director of Nursing | Named in antibiotic stewardship and infection control findings |
| NP | Nurse Practitioner | Named in pain management findings related to resident 22 |
| Wound Nurse | Named in wound care and infection control findings | |
| CNA 4 | Certified Nursing Assistant | Named in wound care and infection control findings |
Inspection Report
Routine
Deficiencies: 22
Date: May 28, 2021
Visit Reason
The inspection was a routine survey of Provo Rehabilitation and Nursing to assess compliance with regulatory requirements including resident rights, medication administration, infection control, care planning, staffing, and quality of care.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights, inadequate medication and self-administration oversight, insufficient staffing, poor infection control practices, inadequate care planning and implementation, delayed and inappropriate pain management, failure to prevent pressure ulcers and falls, inadequate supervision, and poor food quality. Several residents experienced harm due to neglect, abuse allegations were reported but not properly investigated, and infection control lapses were noted.
Deficiencies (22)
Failure to honor resident rights including dignity, self-determination, and communication.
Failure to assess and allow residents to self-administer medications safely.
Failure to reasonably accommodate resident needs and preferences, including call light accessibility.
Failure to promote and facilitate resident self-determination and choice.
Failure to maintain privacy and confidentiality of resident medical records.
Failure to provide a safe, clean, comfortable, and homelike environment including odor control and wheelchair maintenance.
Failure to establish and implement a grievance policy ensuring prompt resolution and documentation of grievances.
Failure to protect residents from abuse and neglect including physical abuse, verbal abuse, neglect of catheter care, and rough treatment during incontinence care.
Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft.
Failure to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities.
Failure to develop and implement a complete care plan that meets all resident needs with measurable timetables and actions.
Failure to provide care and assistance to perform activities of daily living for residents unable to do so, including timely showers and personal hygiene.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Failure to provide appropriate care for residents with limited range of motion and mobility, including restorative nursing services.
Failure to provide safe and appropriate respiratory care including repair and provision of CPAP machine.
Failure to provide safe, appropriate pain management consistent with professional standards and resident preferences.
Failure to ensure sufficient nursing staff with appropriate competencies and skills to provide nursing and related services to assure resident safety and well-being.
Failure to ensure that a working call system was available and functioning in resident rooms and that staff were equipped with radios to respond to call lights.
Failure to ensure residents were free from significant medication errors including delayed insulin administration.
Failure to ensure food and drink was palatable, attractive, and at a safe and appetizing temperature.
Failure to procure food from approved sources and store, prepare, distribute and serve food in accordance with professional standards.
Failure to provide and implement an infection prevention and control program including proper PPE use, hand hygiene, and staff screening.
Report Facts
Deficiencies cited: 25
Residents affected: 51
Staffing: 1
Pressure ulcer size: 4.7
Pressure ulcer size: 4.5
Pain score: 10
Pain score: 8
Pain score: 9
Pain score: 10
Pain score: 8
Pain score: 6
Pain score: 7
Pain score: 3
Pain score: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 7 | Registered Nurse | Named in verbal and physical abuse allegation by resident 105 and resident 101 |
| CNA 8 | Certified Nursing Assistant | Named in rough treatment allegation by resident 17 |
| CNA 11 | Certified Nursing Assistant | Named in resident 99's grievance and concerns about transfers |
| RN 1 | Registered Nurse | Named in medication handling and hand hygiene deficiencies |
| RN 3 | Registered Nurse | Named in pain management and resident care interviews |
| RN 4 | Registered Nurse | Named in staff behavior and CPAP machine interview |
| RN 6 | Registered Nurse | Named in burn treatment and infection control interviews |
| CNA 10 | Certified Nursing Assistant | Named in resident care and hygiene interviews |
| CNA 12 | Certified Nursing Assistant | Named in resident care and grievance interviews |
| CNA 13 | Certified Nursing Assistant | Named in resident care and interview |
| CNA 15 | Certified Nursing Assistant | Named in resident care and call light system interview |
| CNA 16 | Certified Nursing Assistant | Named in infection control interview |
| AS 1 | Activities Staff | Named in COVID-19 positive staff and outbreak interview |
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