Provo Rehabilitation and Nursing

• Fine

  CMS changed the fine from March 16, 2026 from $27,471 to $17,857.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5.

• Special Focus Facility

  CMS now lists this home as a Special Focus Facility candidate.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

5 of 97 Utah homes (5%) got a citation at the immediate jeopardy level in 2026.

• Citation F0695. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on April 3, 2026.

  CMS has cited this home for F0695 4 times since 2021.

• Citation F0600. Severity G: actual harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on April 3, 2026.

  CMS has cited this home for F0600 4 times since 2021.

• Citation F0609. Severity G: actual harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on April 3, 2026.

  CMS has cited this home for F0609 4 times since 2021.

• Citation F0610. Severity G: actual harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on April 3, 2026.

  CMS has cited this home for F0610 2 times since 2023.

• Citation F0658. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on April 3, 2026.

• Citation F0840. Severity G: actual harm, isolated.

  The rule CMS cited: Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

  CMS lists it as corrected on April 3, 2026.

• Citation F0865. Severity G: actual harm, isolated.

  The rule CMS cited: Have a plan that describes the process for conducting QAPI and QAA activities.

  CMS lists it as corrected on April 3, 2026.

• Citation F0908. Severity G: actual harm, isolated.

  The rule CMS cited: Keep all essential equipment working safely.

  CMS lists it as corrected on April 3, 2026.

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CMS fine of $17,857 on March 16, 2026.

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• Fine

  CMS changed the fine from October 21, 2024 from $84,840 to $55,146.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.

• Special Focus Facility

  CMS no longer lists this home as a Special Focus Facility candidate.

CMS lists this as a standard inspection and a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

29 of 97 Utah homes (30%) got a citation at the actual harm level in 2024.

• Citation F0600. Severity G: actual harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on December 2, 2024.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on December 2, 2024.

  CMS has cited this home for F0812 2 times since 2021.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on December 2, 2024.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on December 2, 2024.

  CMS has cited this home for F0689 3 times since 2021.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on December 2, 2024.

• Citation F0697. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on December 2, 2024.

  CMS has cited this home for F0697 3 times since 2021.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on December 2, 2024.

• Citation F0757. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.

  CMS lists it as corrected on December 2, 2024.

  CMS has cited this home for F0757 2 times since 2023.

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CMS lists this as a standard inspection.

• Citation K0321. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on November 15, 2024.

  CMS has cited this home for K0321 2 times since 2023.

• Citation K0374. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Install smoke barrier doors that can resist smoke for at least 20 minutes.

  CMS lists it as corrected on November 15, 2024.

  CMS has cited this home for K0374 2 times since 2023.

• Citation K0211. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Keep aisles, corridors, and exits free of obstruction in case of emergency.

  CMS lists it as corrected on November 15, 2024.

  CMS has cited this home for K0211 2 times since 2023.

• Citation K0223. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

  CMS lists it as corrected on November 15, 2024.

• Citation K0372. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on November 15, 2024.

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CMS fine of $55,146 on October 21, 2024.

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• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

CMS lists this as a standard inspection.

Severity H is the second-highest of CMS's four levels. It means a resident was harmed.

17 of 97 Utah homes (18%) got a citation at the actual harm level in 2023.

• Citation F0600. Severity H: actual harm, pattern.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on March 29, 2023.

• Citation F0692. Severity H: actual harm, pattern.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on March 29, 2023.

• Citation F0835. Severity H: actual harm, pattern.

  The rule CMS cited: Administer the facility in a manner that enables it to use its resources effectively and efficiently.

  CMS lists it as corrected on March 29, 2023.

  CMS has cited this home for F0835 2 times since 2021.

• Citation F0867. Severity H: actual harm, pattern.

  The rule CMS cited: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  CMS lists it as corrected on March 29, 2023.

  CMS has cited this home for F0867 2 times since 2021.

• Citation F0676. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  CMS lists it as corrected on March 29, 2023.

• Citation F0677. Severity G: actual harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on March 29, 2023.

  CMS has cited this home for F0677 2 times since 2021.

• Citation F0684. Severity G: actual harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on March 29, 2023.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on March 29, 2023.

• Citation F0697. Severity G: actual harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on March 29, 2023.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on March 29, 2023.

  CMS has cited this home for F0880 2 times since 2021.

• Citation F0583. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Keep residents' personal and medical records private and confidential.

  CMS lists it as corrected on March 29, 2023.

  CMS has cited this home for F0583 2 times since 2021.

• Citation F0584. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on March 29, 2023.

  CMS has cited this home for F0584 2 times since 2021.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on March 29, 2023.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on March 29, 2023.

  CMS has cited this home for F0550 2 times since 2021.

• Citation F0578. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

  CMS lists it as corrected on March 29, 2023.

• Citation F0604. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

  CMS lists it as corrected on March 29, 2023.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on March 29, 2023.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on March 29, 2023.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on March 29, 2023.

  CMS has cited this home for F0656 2 times since 2021.

• Citation F0661. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

  CMS lists it as corrected on March 29, 2023.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on March 29, 2023.

  CMS has cited this home for F0690 2 times since 2021.

• Citation F0693. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

  CMS lists it as corrected on March 29, 2023.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on March 29, 2023.

• Citation F0757. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.

  CMS lists it as corrected on March 29, 2023.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on March 29, 2023.

• Citation F0770. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide timely, quality laboratory services/tests to meet the needs of residents.

  CMS lists it as corrected on March 29, 2023.

• Citation F0881. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Implement a program that monitors antibiotic use.

  CMS lists it as corrected on March 29, 2023.

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CMS lists this as a standard inspection.

• Citation K0321. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on March 17, 2023.

• Citation K0211. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Keep aisles, corridors, and exits free of obstruction in case of emergency.

  CMS lists it as corrected on March 17, 2023.

• Citation K0374. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install smoke barrier doors that can resist smoke for at least 20 minutes.

  CMS lists it as corrected on March 17, 2023.

• Citation K0920. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on March 17, 2023.

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CMS lists this as a standard inspection.

Severity H is the second-highest of CMS's four levels. It means a resident was harmed.

10 of 97 Utah homes (10%) got a citation at the actual harm level in 2021.

• Citation F0600. Severity H: actual harm, pattern.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on August 10, 2021.

• Citation F0725. Severity H: actual harm, pattern.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on August 10, 2021.

• Citation F0835. Severity H: actual harm, pattern.

  The rule CMS cited: Administer the facility in a manner that enables it to use its resources effectively and efficiently.

  CMS lists it as corrected on August 10, 2021.

• Citation F0867. Severity H: actual harm, pattern.

  The rule CMS cited: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  CMS lists it as corrected on August 10, 2021.

• Citation F0686. Severity G: actual harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on August 10, 2021.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on August 10, 2021.

• Citation F0690. Severity G: actual harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on August 10, 2021.

• Citation F0697. Severity G: actual harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on August 10, 2021.

• Citation F0742. Severity G: actual harm, isolated.

  The rule CMS cited: Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

  CMS lists it as corrected on August 10, 2021.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on August 10, 2021.

• Citation F0550. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on August 10, 2021.

• Citation F0561. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  CMS lists it as corrected on August 10, 2021.

• Citation F0584. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on August 10, 2021.

• Citation F0585. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

  CMS lists it as corrected on August 10, 2021.

• Citation F0607. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  CMS lists it as corrected on August 10, 2021.

• Citation F0609. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on August 10, 2021.

• Citation F0656. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on August 10, 2021.

• Citation F0677. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on August 10, 2021.

• Citation F0726. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

  CMS lists it as corrected on August 10, 2021.

• Citation F0756. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  CMS lists it as corrected on August 10, 2021.

• Citation F0760. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that residents are free from significant medication errors.

  CMS lists it as corrected on August 10, 2021.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on August 10, 2021.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on August 10, 2021.

• Citation F0885. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Report COVID19 data to residents and families.

  CMS lists it as corrected on August 10, 2021.

• Citation F0919. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Make sure that a working call system is available in each resident's bathroom and bathing area.

  CMS lists it as corrected on August 10, 2021.

• Citation F0554. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Allow residents to self-administer drugs if determined clinically appropriate.

  CMS lists it as corrected on August 10, 2021.

• Citation F0558. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on August 10, 2021.

• Citation F0583. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Keep residents' personal and medical records private and confidential.

  CMS lists it as corrected on August 10, 2021.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on August 10, 2021.

• Citation F0688. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

  CMS lists it as corrected on August 10, 2021.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on August 10, 2021.

• Citation F0842. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on August 10, 2021.

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CMS lists this as a standard inspection.

• Citation K0363. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on July 9, 2021.

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