Spanish Fork Rehabilitation and Nursing

In the surveyor’s words

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

• Actual harm, isolatedF689Nov 24, 2025

  Based on observation, interview, and record review, it was determined for 1 of 16 sampled residents, that the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the resident sustained four falls with no new interventions implemented and one of those falls resulted in a head laceration that required ten staples. This was identified at a Harm level. 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.On 11/18/25 at 10:26 AM, resident 4's door was observed to be closed, and no noises could be heard from the… […]

• Actual harm, isolatedF600Oct 5, 2023

  Based on interview and record review, it was determined, for 1 of 21 sampled residents, that the facility did not ensure each residenthas the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, a resident fell and experienced a head laceration and broken ribs after not being checked on for an extended period of time. This resulted in a finding of HARM. Resident identifier: 35. Findings included: HARM Resident 35 was admitted to the facility on [DATE] with diagnoses which included hemipareses and hemiplegia of left non-dominant side, lack of coordination, dysphagia, type II diabetes, muscle weakness, lack of coordination, unsteadiness on feet, gastroesophageal reflux disease, hypertension and Crohn's disease. […]

• No harm, potential for more than minimal, patternF812Nov 24, 2025

  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. […]

• No harm, potential for more than minimal, patternF610Oct 5, 2023

  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,… […]

• No harm, potential for more than minimal, patternF886Nov 10, 2021

  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. […]