Average — CMS composite of the measures below.
The next survey window likely opens around October 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 Spanish Fork Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with Huntington’s disease, severe chorea, cognitive decline, and high fall risk had repeated unwitnessed falls, including one that caused a head laceration requiring 10 staples. Surveyors observed the resident lying sideways at the foot of the bed in a dim room with no staff present, no call light, and no fall mat, while staff said they relied on frequent checks and listening for her because she could not safely use a call light. The record showed multiple falls with no new interventions added after several incidents.
Unsafe food handling and undated spices were observed during tray line service. A cook was seen using a dirty gloved hand to touch plated food, move carts, handle meal tickets, and reposition food on plates, while the same soiled washcloth used to clean surfaces was also used to wipe plate edges and touch plated food. Multiple spice containers were also found without open dates, and the cook stated the spices were opened and used without dating them.
Failure to Update Fall Care Plan After Repeated Falls: A resident with Huntington's disease, aphasia, PTSD, and severe cognitive impairment had a high fall risk and required substantial to maximal assistance with transfers. The care plan listed fall-related interventions, but after multiple falls, including unwitnessed events and one with a new bump to the head, no new interventions were added. The DON and Corporate Nurse stated the resident was unpredictable, often got up suddenly, and that falls were occurring mostly overnight, yet the care plan was not updated to reflect the repeated events.
Inadequate supervision and fall prevention for a resident with Huntington’s disease
Penalty
Summary
The facility did not ensure that a resident with Huntington’s disease, aphasia, anxiety disorder, PTSD, and a prior left femur fracture received adequate supervision and assistance devices to prevent accidents. The resident had severely impaired decision-making, impaired gait, and substantial to maximal assistance needs for standing and transfers. Her care plan identified her as a frequent fall risk with interventions such as keeping frequently used items within reach, providing a high-low bed, assisting with a gait belt, and maintaining a safe environment, while the overall goal remained that she would be free of falls with injury through the review date. The resident experienced multiple falls over several months, including falls on 7/6/25, 8/18/25, 8/29/25, 9/2/25, 10/11/25, 10/12/25, and 10/30/25. Documentation repeatedly noted that the resident had Huntington’s disease with chorea, impulsive movements, and cognitive decline, and several event notes stated that no new interventions were implemented after the falls. After the 9/2/25 unwitnessed fall, the resident was found covered in blood with a laceration to the back of her head and later returned from the emergency department with 10 staples. After the 10/11/25 and 10/12/25 falls, the record again stated there were no new interventions implemented on the care plan. Survey observations showed the resident repeatedly lying sideways at the foot of the bed with her feet hanging off the side, in a dim room, with no staff present, no call light, and no fall mat observed. Staff interviews indicated the resident did not have a call light because of concern she could place the cord around her neck, and staff relied on hearing her because she was loud and verbal when getting up. Staff also stated she was checked on every 15 to 20 minutes, every 30 minutes to an hour, or every hour, but an observation from 1:09 PM to 1:56 PM showed no CNA or nursing staff entered the room for 36 minutes. The DON and other staff stated the resident was unpredictable, would jump out of bed, and that they had not discussed a silent alarm or motion detector; the resident’s room remained closed and monitored primarily by listening for her movements.
Unsafe Food Handling and Undated Spices
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety during lunch tray line service. During observation, a cook was seen wearing gloves and then using a gloved left hand to move a metal cart, plate food, and touch plated food. The same cook was also observed using a washcloth to wipe a cutting board near the tray line, then using that same washcloth to wipe the edges of plates while it touched food that had already been plated. The washcloth was later used to wipe the cook’s gloved hands and to wipe plate edges again, and the cook was observed repeatedly repositioning food on plates with a dirty gloved hand, wiping hands with the washcloth, and touching plated food with both a gloved hand and the soiled washcloth. At one point, a meal ticket that had fallen into the rice container was removed before rice was plated, and the cook used her entire right hand to touch the face of a plate, plate the food, and then wipe the edge of the plate and touch the plated food with the soiled washcloth. During the final kitchen inspection, multiple spice containers were observed without an open date, including parsley flakes, bay leaves, Italian seasoning, onion powder, garlic powder, Spanish paprika, light chili powder, rosemary leaves, ground black pepper, Cajun seasoning, dill weed, crushed red pepper, ground cumin, celery salt, and rubbed sage. In interview, the cook stated the spices were never dated when opened and that the washcloth should not touch the food but could be used to clean the plates. The Dietary Manager stated staff should not touch food with dirty hands or gloves, should change gloves after touching carts, should not wipe plates with the dirty washcloth used for cleaning, and acknowledged that the spices should have been labeled.
Failure to Update Fall Care Plan After Repeated Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with Huntington's disease, aphasia, anxiety disorder, PTSD, and a nondisplaced intertrochanteric fracture of the left femur. The resident's quarterly MDS indicated short- and long-term memory problems, severely impaired decision-making skills, and the need for substantial to maximal assistance with standing and transfers. The care plan identified frequent falls despite environmental modification, therapy, assistive devices, and medication optimization, and it stated that the focus of care was shifting to injury prevention and quality of life, with a goal that the resident would be free of falls with injury through the review date. The care plan included interventions such as anticipating and meeting needs, keeping items within reach, following the fall protocol after a fall, using a high-low bed, maintaining a safe environment, assisting with a gait belt, and placing a toilet riser on the toilet. The resident had multiple falls documented in the record, including falls on 8/18/25, 8/29/25, 10/11/25 and/or 10/12/25, and 10/30/25. One event note stated the resident had refused interventions, and another noted an unwitnessed fall with a new bump on the back right side of the head. After each of these falls, the record indicated there were no new interventions implemented on the care plan. During interview, the DON and Corporate Nurse stated the resident was unpredictable, would stand up and walk toward staff, and would jump out of bed. They also stated the resident's falls were occurring more often between midnight and 6:00 AM, that staff were doing rounding, and that the team had discussed interventions after each fall but believed there was nothing they could do beyond keeping the resident out of her room and checking on her frequently.
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What surveyors actually found near you
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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 Spanish Fork
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonehenge Of Springville | 3.5 mi | ★★★★★ | 0 | 0 |
| Advanced Health Care Of Salem | 5.4 mi | ★★★★★ | 1 | 0 |
| Rocky Mountain Care - Maple Dell | 5.6 mi | ★★★★★ | 1 | 0 |
| Mervyn Sharp Bennion Central Utah Veterans Home | 5.7 mi | ★★★★★ | 1 | 0 |
| Provo Rehabilitation And Nursing | 9.5 mi | ★★★★★ | 8 | 1 |
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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.