Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Orem Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Two high fall risk residents with significant cognitive and physical impairments experienced multiple falls without the facility implementing new or adequate interventions after each incident. Despite repeated falls and clear documentation of high risk, staff did not update care plans or provide increased supervision, relying instead on repeated education and minor environmental changes. Interviews confirmed that interventions were not sufficiently revised to address the ongoing risk, resulting in a failure to maintain a safe environment and prevent accidents.
Several nurse aides were employed for more than four months without completing the required state-approved training and competency evaluation program. Despite the 120-day limit for certification, these aides continued to work until it was discovered and they were removed from the schedule.
Several residents reported that their meals were often cold, bland, or unappetizing, with food fortification practices involving the addition of cold milk or butter to already plated food. Observations confirmed that food was served at improper temperatures and was not consistently palatable, and the dietary manager was unaware of resident dissatisfaction prior to the survey.
Surveyors identified multiple breaches in food safety standards, including unlabeled and undated food items, improper storage of meat above produce, food and cleaning supplies stored together, and staff personal items in food prep areas. Additionally, a staff member was observed handling food and plates with dirty gloves after touching various surfaces, and water was seen dripping onto the plate warmer.
A resident with chronic pain and intact cognition reported receiving the wrong medication from a nurse when requesting prescribed oxycodone. The resident and his daughter noticed discrepancies, including being given a different colored pill and experiencing symptoms consistent with medication errors. Facility investigation, including video review, confirmed that the nurse diverted the resident's narcotic medication and instead administered other medications, leading to substantiated misappropriation.
A resident with hemiplegia, diabetes, and reduced mobility experienced significant delays in receiving timely specialist appointments for hand contractures and foot drop, despite repeated requests and multiple physician orders. The facility's process required several steps and handoffs before appointments could be scheduled, resulting in the resident having to ask multiple times before an appointment was finally arranged.
A resident receiving oxygen therapy for acute respiratory failure was found to have undated nasal cannulas in use, and there was no physician's order in the medical record for changing oxygen supplies. Staff interviews confirmed that nurses were responsible for changing and dating the cannulas, but the absence of an order led to inconsistent practice and lack of documentation.
Nurse staffing information was not posted daily as required, with outdated postings observed and no updates made on weekends. The receptionist responsible for posting the data was absent on certain days, and no other staff took over the task. The weekend receptionist was not trained to post the information, resulting in missing postings that were later completed retroactively.
A resident with multiple chronic conditions had physician orders for several CBC tests, but the corresponding laboratory results were not found in the clinical record. The facility used two EHR systems, and the lab uploaded results to both; however, Medical Records staff only had access to one system, leading to the omission of required lab reports in the resident's record.
Two residents receiving prophylactic antibiotics for UTI were not consistently monitored under an antibiotic stewardship program. The IP tracked antibiotic use only during the month of initiation and did not maintain ongoing monitoring for long-term use, and the DON did not participate in infection control monitoring.
A resident with a history of trauma was denied the right to exit a room by the ADON, triggering distress. The ADON stood in front of the door during a conversation about the resident's inquiries into staff disciplinary actions, preventing her from leaving. The resident felt trapped, recalling past trauma, and the facility's investigation found the ADON's actions inappropriate, though not malicious.
A facility failed to report an abuse allegation involving a resident and the ADON within the required 2-hour timeframe. The incident, which caused the resident distress, was reported to the SSA 27.5 hours later and to APS eight days later. The resident had multiple health conditions, and the Administrator misunderstood the reporting requirements.
Failure to Implement Effective Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to ensure that the environment was as free from accident hazards as possible and did not provide adequate supervision or implement new interventions to prevent accidents for two high fall risk residents. One resident with multiple diagnoses including dementia, muscle weakness, morbid obesity, and unsteadiness on feet was documented as a high fall risk and experienced several falls within a short period. Despite being a full assist and having a history of falls, no new fall prevention interventions were documented in the medical record after each incident. Staff interviews confirmed that no additional interventions were implemented, and the resident was not on continuous observation, even though the resident had fallen multiple times in a short timeframe and was ultimately sent to the hospital after a change in condition. Another resident with epilepsy, brain deformity, unsteadiness, and muscle weakness was also identified as a high fall risk and experienced multiple falls over several months. After each fall, the interventions implemented were often repeated or limited to education and minor environmental changes, such as providing a non-slip mat or instructing on proper footwear. Despite the resident's cognitive delays, impulsivity, and difficulty following instructions, the interventions did not change significantly after repeated falls, and the care plan was not sufficiently updated to address the ongoing risk. Interviews with nursing staff and consultants revealed that both residents required frequent prompting and supervision due to their cognitive and physical limitations. However, the facility did not implement new or different interventions after repeated falls, and the care plans were not adequately revised to prevent further incidents. The lack of timely and appropriate updates to interventions and care plans contributed to the deficiency in maintaining a safe environment and providing adequate supervision for these high-risk residents.
Nurse Aides Worked Beyond 120 Days Without Required Certification
Penalty
Summary
The facility failed to ensure that nurse aides who had been employed for more than four months were trained, competent, and had completed a state-approved training and competency evaluation program. Specifically, three nurse aides were found to have worked at the facility for over four months without obtaining certification as nursing assistants. Employee records showed that these nurse aides continued to work beyond the 120-day period allowed for certification. Interviews with the Administrator and the CNA Coordinator confirmed that the aides had exceeded the permitted timeframe for certification and had only recently been removed from the schedule due to this deficiency.
Failure to Provide Palatable and Appropriately Tempered Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for several residents. Multiple residents on specialized and regular diets reported that their food was often cold, bland, or unappetizing. Observations and interviews revealed that food fortification practices involved adding cold milk or drizzling butter onto already prepared and plated food, rather than incorporating these items during the cooking process. The dietary manager (DM) confirmed that fortification was done by adding unmeasured amounts of butter or cold milk directly to the plated food due to space constraints, and that the exact caloric content provided to residents was not tracked. During tray line service, staff were observed squirting cold milk and drizzling butter onto plated meals, resulting in food that was oily, bland, and not at the appropriate temperature. A test tray showed that the pureed chicken was cold and oily, the couscous was bland, and the broccoli was cool to the taste. Residents consistently reported dissatisfaction with the temperature and palatability of their meals, and the DM was unaware of these complaints prior to the survey. These findings were based on direct observation, interviews with residents and staff, and review of food service practices.
Food Storage and Service Safety Deficiencies
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and service within the facility's kitchen. Unlabeled and undated food items, including a large container of liquid and carafes of juice, were found in the walk-in refrigerator. An opened box of bacon was stored above open produce, and a can of beets was found on the floor in dry storage. Large bins of rice and cereal were not labeled or dated. Staff personal items, such as cellphones and drink cups without lids, were stored on food preparation tables. Cleaning supplies were stored in the same room as fresh produce. Water was observed dripping from a ceiling vent onto the plate warmer. During meal service, a staff member was seen handling plates and food with dirty gloves after touching other surfaces, including plate covers, meal tickets, the faces of plates, a shelf, and an electrical cord. The Dietary Manager confirmed that these practices were not in accordance with facility policy or professional standards, stating that food should not be stored on the floor, meat should be stored below produce, bins should be labeled and dated, and staff should not have personal items in food preparation areas or touch other surfaces before handling food or plates.
Misappropriation of Resident's Pain Medication by Nursing Staff
Penalty
Summary
A resident with diagnoses including cerebral infarction, respiratory failure, and chronic pain syndrome, and who was cognitively intact, reported concerns about receiving incorrect medications from a specific nurse. The resident stated that on multiple occasions, when requesting his prescribed oxycodone for pain, he was given a different colored pill, which he identified as not being his usual pain medication. The resident's daughter also witnessed the administration of a white pill instead of the expected medication and later raised the issue with facility staff. The resident experienced symptoms such as an upset stomach and noted that his pain medication supply depleted faster than expected, while his heart medication was being administered in excess, as confirmed by his physician. The facility's investigation included interviews, review of medication administration records, and examination of video footage. The footage showed the nurse in question accessing the narcotic drawer, removing medication, and placing it in her pocket rather than administering it to the resident. The nurse was also observed preparing pill packs and explaining the process to the resident's daughter, who expressed confusion about the medication packaging. The nurse denied any wrongdoing but could not account for the discrepancies in medication administration. The facility verified that the resident was not administered his prescribed narcotic as ordered and that the nurse had diverted the medication. The nurse was found to have violated the facility's code of conduct regarding drug diversion. The incident was reported to the appropriate authorities, and the nurse was subsequently terminated. The resident was considered a vulnerable adult with full capacity at the time of the incident, and the misappropriation of his medications was substantiated by both facility and external investigations.
Delay in Specialist Referrals for Contractures and Foot Drop
Penalty
Summary
A deficiency was identified when a resident with hemiplegia, hemiparesis, type 2 diabetes mellitus, reduced mobility, and major depressive disorder was not provided timely appointments with referred specialists for hand contractures and foot drop. The resident, who had intact cognition as indicated by a BIMS score of 15, repeatedly requested to see an orthopedic hand surgeon and a podiatrist for worsening contractures and drop foot. Despite multiple encounter notes and physician orders documenting the need for these referrals, there were significant delays in scheduling the appointments. The process for scheduling specialist appointments involved several steps: the in-house physician would order the referral, the floor nurse would enter and print the order for the physician's signature, and the signed order would then be routed to the Director of Transportation (DT) for scheduling. Interviews with staff revealed that the DT could only schedule appointments after receiving the signed order, and that delays could occur due to the need for provider acceptance, insurance verification, and document transmission. The DT, nurses, and DON described a workflow that required multiple handoffs and physical movement of paperwork, which contributed to the delay. Documentation showed that the resident's requests and the need for specialist evaluation were repeatedly noted from early February through late March, with orders for referrals being placed and re-affirmed multiple times. However, the actual appointment for the orthopedic hand surgeon was not scheduled until late April, with the appointment set for early May. The resident reported having to ask multiple times before the appointment was finally arranged, indicating that the facility did not reasonably accommodate her needs and preferences in a timely manner.
Failure to Ensure Proper Orders and Documentation for Oxygen Supply Changes
Penalty
Summary
A deficiency was identified when a resident with acute respiratory failure with hypoxia, epilepsy, and subarachnoid hemorrhage was observed using oxygen therapy without proper documentation or adherence to professional standards for respiratory care. The resident was seen with undated nasal cannulas attached to both an oxygen concentrator and a portable oxygen tank. Multiple staff interviews confirmed that nurses were responsible for changing and dating the nasal cannulas, and that such changes were expected to occur weekly. However, there was no physician's order in the medical record for changing the oxygen supplies, and the cannulas in use were not dated as required. Further review and staff interviews revealed that the process for changing and documenting oxygen supplies was not being followed due to the absence of a physician's order in the resident's medical record. The lack of an order resulted in the failure to consistently change and date the nasal cannulas as per facility protocol and professional standards. This lapse was confirmed by nursing staff and the regional nurse consultant, who acknowledged that the required order was missing and that the changes had not been occurring as expected.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information as required, with observations showing that the posted information was outdated and not updated on weekends. During an initial tour, the nurse staffing posting was found to be several days old. Interviews revealed that the receptionist, who was responsible for posting the staffing data, was absent on certain days and no one else assumed the responsibility in her absence. Additionally, the daily nurse staffing information was not posted on weekends because the weekend receptionist was not trained to do so. For days when the information was not posted, the receptionist later completed the records retroactively and stored them in a binder.
Failure to File Laboratory Reports in Resident Record
Penalty
Summary
A deficiency was identified when it was found that laboratory reports for a resident were not filed in the resident's clinical record as required. The resident, who had multiple diagnoses including type 2 diabetes, congestive heart failure, essential hypertension, schizoaffective disorder, Bell's palsy, anxiety disorder, and depression, had physician orders for Complete Blood Count (CBC) tests on several occasions. However, no laboratory results for the CBCs ordered on three specific dates could be located in the resident's electronic medical record. During interviews, it was revealed that the facility used two electronic health record (EHR) applications, and the laboratory uploaded results to both. The Medical Records staff only had access to one of these applications and could only file results that were uploaded to the system they could access. The missing laboratory results were uploaded to the EHR application that Medical Records did not have access to, resulting in the reports not being filed in the resident's clinical record.
Failure to Monitor Long-Term Antibiotic Use
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program that included protocols and a system to monitor all antibiotic use for residents. Specifically, two residents with orders for prophylactic antibiotics were not adequately monitored. One resident had a physician's order for Keflex 500 mg at bedtime for UTI prophylaxis, and another had a physician's order for Cephalexin 250 mg daily for chronic UTI prophylaxis related to long-term antibiotic use. Record reviews confirmed that these residents were on long-term antibiotic therapy. Interviews with facility staff revealed gaps in the monitoring process. The Infection Preventionist (IP) stated that antibiotic reviews were not consistently performed for residents on long-term prophylactic antibiotics, and tracking was only done for the month the antibiotic was initiated, without ongoing monitoring in subsequent months. The IP also confirmed there was no system in place to track residents on long-term antibiotic use. The Director of Nursing (DON) indicated that she did not participate in infection control monitoring, leaving all antibiotic stewardship responsibilities to the IP.
Resident Denied Right to Exit Room by ADON
Penalty
Summary
The deficiency involved a resident who was denied the right to exit a room by facility staff, specifically the Assistant Director of Nursing (ADON). The resident, who was cognitively intact with a BIMS score of 15, had a history of trauma and was triggered by the ADON's actions. The incident occurred when the ADON brought the resident into his office to address a concern about the resident asking staff about a disciplinary action involving another staff member. During the conversation, the resident attempted to leave, but the ADON stood in front of the door, preventing her from exiting, which caused the resident distress and triggered memories of past trauma. The facility's investigation revealed that the ADON's actions were inappropriate, although not malicious. The ADON admitted to standing in front of the door to stop the resident from leaving, which was confirmed by RN 1, who was present during the conversation. The ADON's demeanor and communication style were perceived as stern and could have been interpreted as intimidating by the resident. The resident reported feeling trapped and compared the situation to past experiences with her ex-husband, which exacerbated her distress. The facility's policy on abuse and involuntary seclusion was reviewed, which defines involuntary seclusion as the separation of a resident from others or confinement against their will. The ADON acknowledged that he should have allowed the resident to leave when she expressed a desire to do so. The incident highlighted a failure to respect the resident's right to freedom from involuntary seclusion, as the ADON's actions effectively confined the resident to the office against her will.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident and the Assistant Director of Nursing (ADON) within the required timeframe. The incident occurred when the ADON brought a resident into his office to discuss a concern raised by a Certified Nurse Assistant (CNA) regarding inappropriate inquiries made by the resident. During the conversation, the resident attempted to leave the office, but the ADON stood in front of the door, insisting on continuing the discussion, which caused the resident distress. This incident was reported to the State Survey Agency (SSA) 27.5 hours after the allegation was made, exceeding the regulatory requirement of reporting within 2 hours if the event involved abuse. The resident involved had multiple diagnoses, including Parkinson's disease, congestive heart failure, and type II diabetes mellitus, among others, and was discharged from the facility on a later date. The facility also failed to notify Adult Protective Services (APS) of the incident until eight days after the allegation was made. The Administrator believed the report to the SSA was timely, misunderstanding the requirement, thinking he had 24 hours to report since the allegation did not result in serious bodily injury.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Orem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspen Ridge Of Utah Valley | 0.7 mi | ★★★★★ | 4 | 0 |
| Provo Rehabilitation And Nursing | 1.8 mi | ★★★★★ | 8 | 1 |
| Stonehenge Of Orem | 2.4 mi | ★★★★★ | 1 | 0 |
| Cascades At Orchard Park | 2.8 mi | ★★★★★ | 0 | 0 |
| Mission At Alpine Rehabilitation Center | 6.7 mi | ★★★★★ | 34 | 5 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.