Spanish Fork Rehabilitation and Nursing

Based on observation, interview, and record review the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the food was not served in a sanitary manner and open spices were not dated. Findings included:On 11/24/25 during the tray line of lunch service the following was observed:a. At 11:55 AM, the [NAME] was observed to don gloves and was then observed to push a metal cart out of the way and then pull it back into position with a gloved left hand. The [NAME] was then observed to plate the lunch meal and use the dirty gloved left hand to touch the food as it was placed onto the plate.b. At 11:57 AM, the [NAME] was observed to use a washcloth to wipe off the cutting board near the tray line. The [NAME] was then observed to use the same wash cloth and wipe the edges of the plate to remove excess food. The wash cloth was observed to touch the food that had already been plated. c. At 11:59 AM, the same wash cloth was observed to be used to wipe the gloved hands of the [NAME] and then used to wipe the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined, for 1 of 16 sampled residents, that the facility failed to develop and implement a comprehensive person-centered care plan for each resident 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; and the comprehensive care plan failed to describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, one resident sustained four falls and no new interventions were implemented on the care plan. Resident identifier: 4.Findings included:Resident 4 was admitted to the facility on [DATE] with diagnoses which included Huntington's disease, aphasia, anxiety disorder, post-traumatic stress disorder, and nondisplaced intertrochanteric fracture of left femur.Resident 4's medical record was reviewed from 11/17/25 through 11/24/25.A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 4 of 21 sampled residents, that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility did not have evidence that all alleged violations were thoroughly investigated. Specifically, allegations of physical, sexual, and verbal abuse were not thoroughly investigated to determine if abuse occurred. Resident identifiers: 24, 31, 35 and 94. Findings include: 1. Resident 24 was admitted to the facility on [DATE], readmitted [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unsteadiness on feet, difficulty in walking not elsewhere classified, dysphagia unspecified, multiple sclerosis, type 2 diabetes mellitus without complications, bladder-neck obstruction, chronic kidney disease stage 3 unspecified, chronic idiopathic constipation, pressure ulcer of sacral region stage 3, pressure ulcer of sacral region unstageable, repeated falls, pressure ulcer of sacral region…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined for 1 of 21 sampled residents, that the facility did not ensure that the resident was free of misappropriation of resident property. Specifically, a nursing assistant stole a resident's credit card and made several unauthorized purchases with the card. Resident identifier: 11. Findings include: Resident 11 was admitted to the facility on [DATE], and readmitted [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, difficulty in walking not elsewhere classified, chronic obstructive pulmonary disease with (Acute) exacerbation, acute and chronic respiratory failure with hypoxia, epilepsy unspecified intractable with status epilepticus, contracture left wrist, major depressive disorder recurrent moderate, generalized anxiety disorder, age-related physical debility, acute candidiasis of vulva and vagina, other lack of coordination, obesity unspecified, lack of physical exercise, unsteadiness on feet,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility did not conduct COVID-19 testing based on the criteria for conducting testing of asymptomatic individuals, such as the positivity rate of COVID-19 in a county. Specifically, unvaccinated staff were not tested twice a week when the county positivity rate was High >10%). This occurred for 2 out of 5 sampled staff members. Findings include: Center for Medicare and Medicaid Services (CMS) Memo QSO (Quality Safety & Oversight)-20-38-NH, revised on 4/27/21, reads, Routine testing of unvaccinated staff should be based on the extent of the virus in the community. Fully vaccinated staff do not have to be routinely tested. Facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency. [Community COVID-19 activity is High when the county positivity rate in the past week was >10% and minimum testing frequency of unvaccinated staff is twice a week.] The Utah County positivity rates used to determine the frequency for routine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review it was determined that the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident with an active diagnosis, medical orders for medication and monitoring of anxiety did not have anxiety addressed in the resident's care plan. This occurred for 1 of 19 sampled residents. Resident identifier: 18. Findings include: Resident 18 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia, pneumonia, atrial fibrillation, chronic pain syndrome, emphysema, major depressive disorder, and major anxiety disorder. On 11/8/21, resident 18's medical record was reviewed. On 10/1/21, resident 18's admission Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation and record review it was determined the facility did not ensure that the resident received proper treatment and assistive devices to maintain vision abilities. Specifically, for 1 out of 19 sampled residents, a resident received a new prescription for eye glasses and the new glasses were not ordered as the resident believed they had been. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] with diagnoses which included paranoid schizophrenia, atrial fibrillation, pulmonary embolism, dysphagia, abnormal gain and mobility, mild cognitive impairment, anxiety disorders, muscle weakness, unspecified lack of coordination, and extrapyramidal and movement disorder. On 11/8/21 at 9:30 AM, resident 1 was observed in her room. Resident 1 was interviewed and stated her eyeglasses were missing. Resident 1 stated she had difficulty seeing and writing without her eyeglasses unless she put her face very close to the object. No eyeglasses were observed on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and medical record review it was determined that the facility did not ensure that PRN (as needed) orders for psychotropic drugs were limited to 14 days, except if the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days and he or she documented their rationale in the resident's medical record and indicated the duration for the PRN order. Specifically, a resident, who had psychotropic drug PRN orders that remained active for more than 14 days without a duration specified by the prescribing practitioner. This occurred for 1 of 19 residents. Resident identifier: 18. Findings include: Resident 18 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia, pneumonia, atrial fibrillation, chronic pain syndrome, emphysema, major depressive disorder, and major anxiety disorder. On 11/8/21, resident 18's medical record was reviewed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.