Orem Rehabilitation and Nursing Center

Inspectors wroteBased on observation, interview, and record review it was determined, for 2 of 28 sample residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, two high fall risk residents did not have interventions put in place after multiple falls. Resident identifiers: 18 and 69.

Inspectors wroteBased on interview and record review, the facility did not ensure that any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, was competent to provide nursing and nursing related services; and completed a training and competency program, or a competency evaluation program approved by the State. Specifically, Nurse Aides (NA) were employed at the facility, for over 4 months without completion of training and competency evaluation program.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, for 7 out of 28 sampled resident, residents complained of the quality and temperature of the food, food was being fortified with a squirt of cold milk or splash of butter on the already prepared food, a test tray was not palatable and the food was cold. Resident identifiers: 19, 29, 35, 39, 41, 47 and 59.

Inspectors wroteBased on observation and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were unlabeled and undated food items stored in the kitchen, there was food stored on the floor in the kitchen, meat was improperly stored in the walk-in refrigerator, staff cellphones and beverages were stored in food preparation areas, and staff did not serve food in a hygienic manner. Findings Include: On 4/28/25 at 8:41 AM, an initial observation of the kitchen was conducted. On 4/28/25 at 8:47 AM, an observation was made of the walk in refrigerator. There was an undated, unlabeled liquid in a 22 quart container. There was an opened box of bacon stored on a shelf above open boxes of bananas and oranges. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide reasonable accommodations of needs and preferences except when to do so would endanger the health or safety of resident or other residents for 1 of 28 sampled residents. Specifically, a resident was not provided timely appointments to referred specialists for hand contractures and foot drop. Resident identifier: 41.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that each resident who needed respiratory care was provided such care consistent with professional standards of practice. Specifically, 1 out of 28 sample residents, did not have an order to change the oxygen tubing and humidifier. Resident identifier:

Inspectors wroteBased on observation and interview, the facility did not have the nurse staffing information posted. The facility must post the nurse staffing data on a daily basis at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Specifically, nurse staffing information was out of date and not posted on weekends.

Inspectors wroteBased on interview and record review it was determined for, 1 out of 28 sample residents, that the facility did not file, in the resident's clinical record, laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, a resident's laboratory results were not located in the electronic medical records. Resident identifier:

Inspectors wroteBased on interview and record review, it was determined, for 2 or 28 sampled residents, the facility failed to keep an antibiotic stewardship program that included antibiotics use protocols and a system to monitor all antibiotic use for all residents. Specifically, residents with orders for prophylaxis antibiotics were not monitored for their antibiotic use. Resident identifier: 23 and 28.

Inspectors wroteBased on interview and record review, it was determined that the facility did not prevent misappropriation of a resident's medications for 1 of 28 sampled residents. Specifically, a resident had a nurse tell him he was getting his pain medication but was replacing it with another medication on multiple occasions. Resident identifier: 170.

Inspectors wroteBased on interview and record review it was determined, for 1 of 7 sampled residents, that the facility did not ensure that the resident had the right to be free from abuse including involuntary seclusion. Specifically, the resident was seeking egress from a room and was denied the right to exit by facility staff. Resident identifier 2.

Inspectors wroteBased on interview and record review it was determined, for 1 of 7 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later than 2 hours after the allegation was made if the events that cause the allegation involved abuse to the administrator of the facility, the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, an allegation of abuse was not reported to the SSA or APS within 2 hours of the allegation being made. Resident identifier 2.

Inspectors wroteBased on observation, interview and record review, it was determined for 8 out of 40 sampled residents, that the facility failed to protect residents form abuse. Specifically, residents were sexually abused without ongoing interventions to prevent further abuse. Additionally, the facility had prior knowledge of the alleged perpetrators sexual behaviors and the facility failed to provide protection for the residents thereby allowing ongoing access to the residents by the alleged perpetrator. Finally, victims of the sexual abuse exhibited crying and expressed recurring fear of the perpetrator. Based on the resident(s) behavior, it can be determined that the resident(s) experienced psychosocial harm as a result of the sexual abuse. This identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifiers: 3, 10, 18, 24, 26, 31, 34, and 136. [...]

Inspectors wroteBased on interview and record review it was determined, for 9 out of 40 sampled residents, that in response to allegations of abuse the facility failed to have evidence that all alleged violations were thoroughly investigated and further potential abuse was prevented. Specifically, the facility initial entity reports and final investigation reports filed with the State Survey Agency (SSA) contained incomplete summaries of incidents of sexual abuse, and the facility did not have supporting documentation of the summaries that were provided to the SSA. Additionally, not all reported incidents of alleged sexual abuse had evidence that suggested they were investigated by the facility. Multiple instances of resident to resident sexual abuse occurred with an insufficient investigation. This identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. [...]

Inspectors wroteBased on interview and record review, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple residents were identified to be in Immediate Jeopardy for allegations of sexual abuse. Resident identifiers: 3, 10, 18, 24, 26, 31, 34, and 136.

Inspectors wroteBased on interview and record review, the facility did not establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The facility did not develop and implement policies addressing how they would use a systematic approach to determine underlying causes of problems impacting larger systems; how they would develop corrective actions that would be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and how the facility would monitor the effectiveness of its performance improvement activities to ensure that improvements were sustained. Specifically, multiple residents were identified to be in Immediate Jeopardy for allegations of sexual abuse. Resident identifiers: 3, 10, 18, 24, 26, 31, 34, and 136.

Inspectors wroteBased on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that the resident had the right to self-determination through support of the resident's choices. Specifically, a resident requested a bathing schedule that would provide three showers a week and the facility did not accommodate the request. Resident identifier 34.

Inspectors wroteBased on interview and record review, it was determined, for 1 of 40 sampled residents, that the facility failed to protect the residents from the right to be free from misappropriation of property. Specifically, a staff member at the facility used a resident's credit card for multiple personal purchases. Resident identifier: 1.

Inspectors wroteBased on interview and record review it was determined, for 2 of 40 sampled residents, that the facility did not ensure that all alleged violations involving abuse, neglect, and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA) and Adult Protective Services (APS). Specifically, the facility did not notify the SSA and APS of an allegation of sexual abuse within the two hours of becoming aware of the the incident. Resident identifier 26 and 10.

Inspectors wroteBased on interview and record review, it was determined for 1 of 40 sampled residents that the facility did not ensure the comprehensive care plan included the services needed to achieve the highest practicable physical, mental and psychosocial well-being. Specifically, a resident was found to be taking medications not prescribed by a physician on 3 different occasions which was not addressed in the comprehensive care plan. Resident identifier: 41.

Inspectors wroteBased on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure a resident with urinary incontinence was provided appropriate treatment and services to prevent urinary tract infection (UTI). Specifically, a resident reported staff did not perform sanitary incontinence care and caused a UTI. Resident identifier: 21.

Inspectors wroteBased on observation, interview, and record review, it was determined for 1 of 40 sampled residents that the facility did not ensure parental fluids were administered consistent with professional standards of practice and in accordance with physician orders. Specifically, parental fluids were administered without a documented physician order and the intravenous fluid (IV) tubing was not labeled per facility policy. Resident identifier: 327.

Inspectors wroteBased on interview and record review, it was determined for 1 of 40 sampled residents that the facility did not ensure the needed behavioral health care services were provided to achieve the highest practicable physical, mental and psychosocial well-being. Specifically, a resident was not offered behavioral health care services after she was suspected of self harm and was found taking another residents medication. Resident identifier: 41.

Inspectors wroteBased on interview and record review, it was determined that for 1 of 40 sampled residents, the facility did not ensure that resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, the facility administered blood pressure medications when the blood pressure was outside of physician ordered parameters. Resident identifier: 21.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 40 sampled residents, that the facility did not ensure that an as needed (PRN) order for a psychotropic drug was limited to 14 days unless the attending physician documented a rationale to extend the order with a duration for use. Specifically, a resident was prescribed a PRN order for Lorazepam that exceeded the 14 day limit and there was no documentation for a rationale to extend the order nor a duration for use. Resident identifier 24.

Inspectors wroteBased on interview and record review, it was determined that for 3 of 40 sampled residents, that the facility did not ensure that its residents were free of significant medication errors. Specifically, a resident was sharing her Suboxone with another resident, and a nurse administered a resident a double dosage of Percocet. Resident identifiers: 5, 41, and 45.

Inspectors wroteBased on observation, interview and record review, it was determined for 1 of 33 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident's care plan was not current regarding falls and pain. Resident identifier: 49.

Inspectors wroteBased on record review and interview, it was determined, for 1 of 33 sample residents, that the facility did not maintain medical records on each resident that were complete and accurately documented. Specifically, a notification of room change document was missing from a resident's medical record. Resident identifier 48.

Inspectors wroteBased upon interviews and record review, it was determined that the facility did not ensure that the certified Infection Preventionist (IP) attended the facility's quality assessment and assurance committee meetings on a regular basis. Specifically, the IP had not attended any quality assessment and assurance committee meetings in the past 6 months.