Mission at Nephi Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Mission at Nephi Nursing and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Jun 5, 2023

  Based 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, a staff member was observed to prepare a residents meal and did not change gloves or use hand hygiene after touching multiple kitchen appliances. Findings include: On 6/1/23 at 12:30 PM, an observation of lunch tray line was performed. The following observations were made: a. An observation was made of the Dietary Manager Assistant (DMA) leave the active lunch tray line to find other kitchen utensils. On return to the tray line the (DMA) was observed to pick up the food scoop and start to scoop food. The DMA was then reminded to change her gloves by the Corporate Dietary Director (CDD). […]

• No harm, potential for more than minimal, patternF880Jun 5, 2023

  Based on observation and interview it was determined, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 2 out of 19 sampled residents, a staff member was observed to touch a resident medications with bare hands with each medication administration. Also medications were dropped on and in the medication cart and then administered to the residents. Resident identifiers: 15 and 79. Findings include: On 6/1/23 at 7:30 AM, during morning medication pass the following was observed: a. […]

• No harm, potential for more than minimal, patternF880Sep 2, 2021

  Based on observation and interview it was determined, for 5 of 22 sampled residents that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including [CONDITION(S)]-CoV-2. Specifically, soiled Person Protective Equipment (PPE) was observed to be stored on top of a cart containing clean PPE, signage was not on resident doors that required PPE, staff were observed to touch food with bare hands and food was transported through the halls uncovered. Resident identifiers: 18, 19, 21, 81 and 181. Findings include: 1. […]

• No harm, potential for more than minimal, isolatedF657May 29, 2025

  Based on interview and medical record review, it was determined, for 1 of 27 sampled residents, that the facility did not revise the comprehensive care plan. Specifically, the resident sustained two falls with no new interventions implemented on the care plan. Resident identifier: 17. Findings include: Resident 17 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, dementia, and depression. Resident 17's medical record was reviewed 5/27/25 through 5/29/25. A Quarterly Minimum Data Set (MDS) Assessment, dated 2/20/25, indicated, [Section] C1000. Cognitive Skills for Daily Decision Making . […]

• No harm, potential for more than minimal, isolatedF689May 29, 2025

  Based on observation, interview, and record review, it was determined for 1 of 27 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as is possible; and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the resident sustained two falls with no new interventions implemented and did not have a non-alarming pressure pad on their bed and wheelchair as indicated on the care plan. Resident identifier: 17. Findings include: Resident 17 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, dementia, and depression. On 5/28/25 at 1:12 PM, an observation was made of resident 17's bed and resident 17 sitting in his wheelchair. […]