A list of the most recent deficiencies for Provo Rehabilitation and Nursing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Keep residents' personal and medical records private and confidential. | Health | 2023-01-30 | 2023-03-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-30 | 2023-03-29 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-01-30 | 2023-03-29 | Y |
| 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. | Health | 2023-01-30 | 2023-03-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-30 | 2023-03-29 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-01-30 | 2023-03-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-30 | 2023-03-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-30 | 2023-03-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-30 | 2023-03-29 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-01-30 | 2023-03-29 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-01-30 | 2023-03-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-30 | 2023-03-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-30 | 2023-03-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-30 | 2023-03-29 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-30 | 2023-03-29 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-30 | 2023-03-29 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-01-30 | 2023-03-29 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-30 | 2023-03-29 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-01-30 | 2023-03-29 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-01-30 | 2023-03-29 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-30 | 2023-03-29 | Y |
| 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. | Health | 2023-01-30 | 2023-03-29 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-01-30 | 2023-03-29 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-01-30 | 2023-03-29 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-30 | 2023-03-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-30 | 2023-03-29 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-01-30 | 2023-03-29 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-01-30 | 2023-03-29 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-24 | 2023-03-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-24 | 2023-03-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-24 | 2023-03-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-24 | 2023-03-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-03 | 2022-12-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-03 | 2022-12-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-03 | 2022-12-05 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-11-03 | 2022-12-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-01 | 2022-06-17 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-05-28 | 2021-08-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-28 | 2021-08-10 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-05-28 | 2021-08-10 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-05-28 | 2021-08-10 | N |
| 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. | Health | 2021-05-28 | 2021-08-10 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-28 | 2021-08-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-28 | 2021-08-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-28 | 2021-08-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-28 | 2021-08-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-28 | 2021-08-10 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-05-28 | 2021-08-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-05-28 | 2021-08-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-28 | 2021-08-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-28 | 2021-08-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-05-28 | 2021-08-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-28 | 2021-08-10 | N |
| Report COVID19 data to residents and families. | Health | 2021-05-28 | 2021-08-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-05-28 | 2021-08-10 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-05-28 | 2021-08-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-28 | 2021-08-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-28 | 2021-08-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-28 | 2021-08-10 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-05-28 | 2021-08-10 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-28 | 2021-08-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-05-28 | 2021-08-10 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-05-28 | 2021-08-10 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-05-28 | 2021-08-10 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-05-28 | 2021-08-10 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-05-28 | 2021-08-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-28 | 2021-08-10 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-05-28 | 2021-08-10 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-05-28 | 2021-08-10 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-26 | 2021-07-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-20 | 2019-08-16 | N |
| 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. | Health | 2019-06-20 | 2019-08-16 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-06-20 | 2019-08-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-20 | 2019-08-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-20 | 2019-08-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-06-20 | 2019-08-16 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-06-20 | 2019-08-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-20 | 2019-08-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-20 | 2019-08-16 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-06-20 | 2019-08-16 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-06-20 | 2019-08-16 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-06-20 | 2019-08-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-06-20 | 2019-08-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-06-20 | 2019-08-16 | N |
| 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. | Health | 2019-06-20 | 2019-08-16 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-06-20 | 2019-08-16 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-06-20 | 2019-08-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-20 | 2019-08-16 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2019-06-20 | 2019-08-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-06-20 | 2019-08-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-06-20 | 2019-08-16 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2019-06-20 | 2019-08-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-06-19 | 2019-08-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-19 | 2019-08-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-19 | 2019-08-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-06-19 | 2019-08-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-19 | 2019-08-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-19 | 2019-08-15 | N |
