Cycle 1
Health 2024-10-21 · Fire 2024-10-21
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Provo, UT
Provo Rehabilitation and Nursing
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
1001 North 500 West, Provo, UT
(801) 377-9661
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
220
Certified beds
Average residents
137
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1988-11-07
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
1.01
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
4.01
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.53
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.74
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
0.77
CMS adjusted RN staffing hours
Adjusted total hours
3.07
CMS adjusted total nurse staffing hours
Case-mix index
1.79
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,857
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.87
Baseline 18.20% · Performance 19.17% · Measure score 4.87 · Achievement 4.87 · Improvement 0
Healthcare-associated infections
0
Baseline 6.30% · Performance 7.71% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.12
Baseline 50.43% · Performance 59.12% · Measure score 1.12 · Achievement 1.12 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.16 hours · Performance 3.21 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.24% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 13.92% · Lower 95% interval 8.07% |
| Discharge to community | 50.69% |
50.57%
0.1 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 41.67% · Lower 95% interval 34.99% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 24 · Denominator 24 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 24 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 24 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.71% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 15.22% · Lower 95% interval 4.86% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 228 |
| Staff flu vaccination coverage | 25.16% |
42%
16.8 pts worse
|
Numerator 77 · Denominator 306 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.2
0.1 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 2.2 · Expected 3.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.9 · Expected 2.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.4% |
96.8%
4.4 pts worse
|
93.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 96.6% · Q3 87.0% · Q4 92.0% · 4Q avg 92.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.1% |
98.0%
10.9 pts worse
|
95.5%
8.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
2.6%
1 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.3% · Q3 1.1% · Q4 0.9% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.3% |
16.1%
0.2 pts worse
|
11.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 14.9% · Q3 22.9% · Q4 18.4% · 4Q avg 16.3% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
3.8%
0.4 pts worse
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 8.6% · Q3 5.7% · Q4 1.9% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.7% |
24.1%
3.4 pts better
|
19.6%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 20.7% · Q3 21.3% · Q4 21.1% · 4Q avg 20.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.7% |
15.4%
5.7 pts better
|
16.7%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 5.3% · Q3 8.6% · Q4 11.1% · 4Q avg 9.7% · 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 | 12.3% |
18.3%
6 pts better
|
16.3%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 10.9% · Q3 6.4% · Q4 15.8% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
13.6%
4.9 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 8.6% · Q3 7.0% · Q4 10.1% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.8% · Q4 1.2% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.8%
0.2 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.1% · Q4 3.6% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.7% |
22.4%
6.3 pts worse
|
19.8%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 26.9% · Q3 24.8% · Q4 35.3% · 4Q avg 28.7% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
4.1%
2.6 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 7.7% · Q3 7.4% · Q4 7.1% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.8% |
93.3%
5.5 pts worse
|
81.7%
6.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.9% · Q2 88.8% · Q3 92.2% · Q4 86.7% · 4Q avg 87.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.2% |
11.8%
4.6 pts better
|
12.0%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.2% · Observed 10.4% · Expected 16.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
0.9%
0.9 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.0% |
91.0%
17 pts worse
|
79.7%
5.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.0% |
17.4%
2.4 pts better
|
23.9%
8.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 22.9% · Expected 36.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-30 · Fire 2023-01-30
27 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-05-28 · Fire 2021-05-28
32 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-15
F · Potential for more than minimal harm
2024-10-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-10-21
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-10-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-15
F · Potential for more than minimal harm
2023-01-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-01-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-01-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-01-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-17
D · Potential for more than minimal harm
2021-05-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-07-09
Inspection history
Recent health citations
G · Actual harm
2024-10-21
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 2024-12-02
E · Potential for more than minimal harm
2024-10-21
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 2024-12-02
D · Potential for more than minimal harm
2024-10-21
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 2024-12-02
D · Potential for more than minimal harm
2024-10-21
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 2024-12-02
D · Potential for more than minimal harm
2024-10-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-10-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-02
H · Actual harm
2023-01-30
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 2023-03-29
H · Actual harm
2023-01-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-29
H · Actual harm
2023-01-30
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-03-29
H · Actual harm
2023-01-30
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-03-29
G · Actual harm
2023-01-30
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-03-29
G · Actual harm
2023-01-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-29
G · Actual harm
2023-01-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-29
G · Actual harm
2023-01-30
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 2023-03-29
G · Actual harm
2023-01-30
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-03-29
F · Potential for more than minimal harm
2023-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-29
E · Potential for more than minimal harm
2023-01-30
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-03-29
E · Potential for more than minimal harm
2023-01-30
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-03-29
E · Potential for more than minimal harm
2023-01-30
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-01-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-01-30
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-01-30
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-01-30
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 2023-03-29
D · Potential for more than minimal harm
2023-01-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-01-30
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 2023-03-29
D · Potential for more than minimal harm
2023-01-30
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-01-30
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 2023-03-29
D · Potential for more than minimal harm
2023-01-30
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-01-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-01-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-01-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-01-30
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-03-29
D · Potential for more than minimal harm
2023-01-30
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-03-29
H · Actual harm
2021-05-28
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 2021-08-10
H · Actual harm
2021-05-28
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2021-08-10
H · Actual harm
2021-05-28
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2021-08-10
H · Actual harm
2021-05-28
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2021-08-10
G · Actual harm
2021-05-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-08-10
G · Actual harm
2021-05-28
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 2021-08-10
G · Actual harm
2021-05-28
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 2021-08-10
G · Actual harm
2021-05-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-08-10
G · Actual harm
2021-05-28
F742 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2021-08-10
F · Potential for more than minimal harm
2021-05-28
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 2021-08-10
E · Potential for more than minimal harm
2021-05-28
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-08-10
E · Potential for more than minimal harm
2021-05-28
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 2021-08-10
E · Potential for more than minimal harm
2021-05-28
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2021-08-10
E · Potential for more than minimal harm
2021-05-28
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2021-08-10
E · Potential for more than minimal harm
2021-05-28
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2021-08-10
E · Potential for more than minimal harm
2021-05-28
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 2021-08-10
E · Potential for more than minimal harm
2021-05-28
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 2021-08-10
E · Potential for more than minimal harm
2021-05-28
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-08-10
E · Potential for more than minimal harm
2021-05-28
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2021-08-10
E · Potential for more than minimal harm
2021-05-28
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-08-10
E · Potential for more than minimal harm
2021-05-28
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-08-10
E · Potential for more than minimal harm
2021-05-28
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-08-10
E · Potential for more than minimal harm
2021-05-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-10
E · Potential for more than minimal harm
2021-05-28
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2021-08-10
E · Potential for more than minimal harm
2021-05-28
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2021-08-10
D · Potential for more than minimal harm
2021-05-28
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2021-08-10
D · Potential for more than minimal harm
2021-05-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-08-10
D · Potential for more than minimal harm
2021-05-28
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2021-08-10
D · Potential for more than minimal harm
2021-05-28
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-08-10
D · Potential for more than minimal harm
2021-05-28
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2021-08-10
D · Potential for more than minimal harm
2021-05-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-08-10
D · Potential for more than minimal harm
2021-05-28
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 2021-08-10
Penalties and ownership
What sits behind the stars
$55,146
2024-10-21
Fine
Fine · fine $55,146
Fine
Ownership
Beaver Valley Hospital
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Hoopes, Travis
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Martinez, Mark
Operational/Managerial Control · Individual
Moss, Tyler
Corporate Officer · Individual
Nursa Inc
Operational/Managerial Control · Organization
Riverview Healthcare, Inc.
Operational/Managerial Control · Organization
Rubicon Staffing LLC
Operational/Managerial Control · Organization
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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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