Provo Rehabilitation and Nursing

In the surveyor’s words

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

• Immediate jeopardy, isolatedF695Mar 16, 2026

  Based on interview and record review, it was determined that the facility failed to provide respiratory care and tracheostomy care to residents who required these services. Specifically, for 3 out of 9 sampled residents, staff did not follow physician orders for changing tracheostomies; staff were not obtaining needed consultations with outside providers; staff were not accurately documenting the resident condition prior to the tracheostomy change; staff did not initiate a hospital transfer for a resident with concerns about the integrity of the tracheostomy. Additionally, staff interviews revealed knowledge of faulty equipment with a resident experiencing a broken flange which caused a dislodged tracheostomy, and subsequently going into cardiac arrest and dying. […]

• Actual harm, patternF600Jan 30, 2023

  Based on interview, record review, and observation the facility did not ensure that 7 of 54 sample residents were free of neglect. Specifically, residents were not assisted with activities of daily living, had untreated pain, experienced weight loss, experienced falls with injuries, and obtained wounds. The findings for all the residents listed in this deficiency were cited at a harm level. Resident identifiers: 22, 27, 33, 47, 146, 244, and 298. Findings include: HARM ASSISTANCE WITH TOILETING 1. Resident 27 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia, Parkinson's disease, neurocognitive disorder with Lewy Bodies, neuropathy, and insomnia. […]

• Actual harm, patternF692Jan 30, 2023

  Based on interview, observation and record review, the facility did not ensure that 3 of 54 sample residents maintained acceptable parameters of nutritional status. Specifically, residents with weight loss did not receive timely and appropriate interventions. This will be cited at a harm level for all three residents. Resident identifiers: 33, 47, and 244. Findings include: HARM 1. Resident 33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, anxiety disorder, osteoporosis, pseudobulbar affect, major depressive disorder, and hypertension. Resident 33's medical record was reviewed on 1/23/23. Resident 33's weights were recorded as follows: a. […]

• Actual harm, patternF835Jan 30, 2023

  Based on interview, record review, and observation, the facility failed to be 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, residents experienced neglect, did not receive assistance with activities of daily living, experienced pain without timely intervention, developed wounds, experienced falls with injuries, and experienced weight loss without timely intervention. This resulted in seven deficiencies cited at a harm level. In addition, multiple deficiencies that were cited on the previous recertification survey and complaint surveys were re-cited on the current survey. […]

• Actual harm, patternF867Jan 30, 2023

  Based on interview, record review, and observation, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies; and regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements. Specifically, residents experienced neglect, did not receive assistance with activities of daily living, experienced pain without timely intervention, developed wounds, experienced falls with injuries, and experienced weight loss without timely intervention. This resulted in seven deficiencies cited at a harm level. […]