Orem Rehabilitation and Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, patternF600Jul 18, 2023

  Based 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. […]

• Immediate jeopardy, patternF610Jul 18, 2023

  Based 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. […]

• Immediate jeopardy, patternF880Apr 23, 2021

  Based on observation, interview, and record review it was determined that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of COVID-19. Specifically, the facility staff were observed to reuse gowns and face shields without disinfecting between use, staff used the same Personal Protective Equipment (PPE) between resident rooms, staff entered quarantine/isolation rooms without gowns and N95 mask as indicated, masks were observed worn improperly, PPE was observed stored improperly, hand hygiene was not performed after resident care, and the quarantine/isolation unit was accessible by all facility staff and residents. The failure had the potential to expose and transmit COVID-19 to staff and residents. […]

• Actual harm, isolatedF603May 22, 2024

  Based 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. Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease, congestive heart failure, atrial flutter, type II diabetes mellitus, chronic kidney disease, morbid obesity, chronic pain, difficulty with walking, polyneuropathy, hypertension, obstructive sleep apnea, and thrombocytopenia. Resident 2 was discharged from the facility on 3/30/24. […]

• Actual harm, isolatedF835Jul 18, 2023

  Based 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. Findings included: 1. Based 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. […]