Cycle 1
Health 2025-05-01 · Fire 2025-05-01
10 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Orem, UT
Orem Rehabilitation and Nursing Center
3-star overall rating with 2-star inspections with abuse icon flag with $38,357 in total fines with 10 recent health deficiencies
575 East 1400 South, Orem, UT
(801) 225-4741
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1986-09-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.84
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.51
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.98
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.65
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
0.85
CMS adjusted RN staffing hours
Adjusted total hours
3.56
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,435
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.67
Baseline 58.54% · Performance 52.75% · Measure score 2.67 · Achievement 2.67 · Improvement 1.22
Adjusted total nurse staffing
1.40
Baseline 3.59 hours · Performance 3.48 hours · Measure score 1.40 · Achievement 1.40 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.09% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 8% · Lower 95% interval 6.65% |
| Discharge to community | 49.8% |
50.57%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 45.95% · Lower 95% interval 37.95% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 22 · Denominator 22 |
| Falls with major injury | 4.55% |
0.77%
3.8 pts worse
|
Numerator 1 · Denominator 22 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4.55% |
2.29%
2.3 pts worse
|
Numerator 1 · Denominator 22 · Adjusted rate 6.19% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.82% |
8.2%
5.4 pts worse
|
Numerator 4 · Denominator 142 |
| Staff flu vaccination coverage | 28.09% |
42%
13.9 pts worse
|
Numerator 50 · Denominator 178 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.0% |
96.8%
2.8 pts worse
|
93.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.8% · Q2 93.3% · Q3 96.6% · Q4 94.4% · 4Q avg 94.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.0%
2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.2% |
16.1%
5.9 pts better
|
11.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 2.0% · Q3 11.8% · Q4 18.4% · 4Q avg 10.2% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
3.8%
1.9 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 1.9% · Q4 4.3% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.3% |
24.1%
9.2 pts worse
|
19.6%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.4% · Q2 31.6% · Q3 33.3% · Q4 27.1% · 4Q avg 33.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.4% |
15.4%
11 pts better
|
16.7%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.5% · Q3 2.5% · Q4 5.7% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.5% |
18.3%
2.8 pts better
|
16.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 9.1% · Q3 10.6% · Q4 20.9% · 4Q avg 15.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.9% |
13.6%
6.7 pts better
|
14.9%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 0.0% · Q3 1.9% · Q4 18.2% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.8%
0.9 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.5% |
22.4%
4.9 pts better
|
19.8%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.0% · Q2 16.3% · Q3 12.2% · Q4 20.7% · 4Q avg 17.5% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.1%
0.2 pts worse
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 5.0% · Q3 4.1% · Q4 1.5% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.6% |
93.3%
2.3 pts better
|
81.7%
13.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 96.1% · Q3 98.5% · Q4 92.8% · 4Q avg 95.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
11.8%
11.8 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
0.9%
0.1 pts worse
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 2.5% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.3% |
91.0%
4.3 pts better
|
79.7%
15.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.0% |
17.4%
0.6 pts worse
|
23.9%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 17.4% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-18 · Fire 2023-07-18
16 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-02-10 · Fire 2022-02-10
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-01
E · Potential for more than minimal harm
2025-05-01
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2025-07-01
E · Potential for more than minimal harm
2025-05-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-07-01
E · Potential for more than minimal harm
2025-05-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-05-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-05-01
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-05-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-05-01
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-05-01
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-05-01
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-07-01
G · Actual harm
2024-05-22
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-05-22
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-19
K · Immediate jeopardy
2023-07-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-29
K · Immediate jeopardy
2023-07-18
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-29
G · Actual harm
2023-07-18
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-08-29
G · Actual harm
2023-07-18
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-07-18
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-07-18
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-07-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-07-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-07-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-07-18
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-07-18
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-07-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-07-18
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-08-29
D · Potential for more than minimal harm
2023-07-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-29
D · Potential for more than minimal harm
2022-02-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-04-01
D · Potential for more than minimal harm
2022-02-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-04-01
D · Potential for more than minimal harm
2022-02-10
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-04-01
Penalties and ownership
What sits behind the stars
$38,357
2023-07-18
Fine
Fine · fine $38,357
Fine
Ownership
Beaver Valley Hospital
5% Or Greater Direct Ownership Interest · Organization
Albrechtsen, Joshua
Operational/Managerial Control · Individual
Burnam, Soon
Operational/Managerial Control · Individual
Burnam, Soon
Corporate Officer · Individual
Davidson, Craig
Corporate Officer · Individual
Hueneme Healthcare, Inc.
Operational/Managerial Control · Organization
Moss, Tyler
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Aspen Ridge of Utah Valley
Orem, UT
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Provo Rehabilitation and Nursing
Provo, UT
3-star overall rating with 2-star inspections with abuse icon flag with $55,146 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Stonehenge of Orem
Orem, UT
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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