Inspection Reports for
Aspen Ridge Residences of Lehi
564 West Main Street, Lehi, UT, 84043
Back to Facility ProfileDeficiencies (over last year)
Deficiencies (over last year)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
103% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Original Licensing
Deficiencies: 16
Date: Oct 30, 2023
Visit Reason
Initial, unannounced inspection of Aspen Ridge Residences of Lehi assisted living facility to assess compliance with state regulations for licensing and operation.
Findings
The inspection identified 18 rule noncompliances covering various regulatory requirements including administrator qualifications, personnel training, resident assessments, service plans, medication administration, emergency preparedness, housekeeping, and facility records. Several deficiencies related to documentation, training, and safety were noted.
Deficiencies (16)
R432-270-8(7)(a)-(f) Five employees did not receive documented orientation training within 30 days of hire covering ethics, confidentiality, resident rights, fire and disaster plan, policies, abuse reporting, and core competency.
R432-270-10(8)(a)-(g) Six resident admission agreements did not specify refund provisions addressing thirty-day notices, emergency transfers or discharges, and resident death.
R432-270-10(10)(a)-(c) Two residents' emergency evacuation plans were not incorporated into their service plans and two residents lacked hospice care plans.
R432-270-12(1) Two residents' assessments were not completed prior to admission.
R432-270-12(4) Four resident assessments lacked a statement signed by a licensed health care professional confirming admission and level of assistance criteria.
R432-270-13(3)(a)-(e) Three residents' service plans did not include who would provide services and the frequency of services.
R432-270-18(2)(a)-(f) One resident did not receive medication as prescribed.
R432-270-18(7) RN was not notified when a medication error occurred for one medication not being available.
R432-270-18(8) Medication error incident reports were not completed when medication errors occurred or were identified.
R432-270-25(11)(a)-(b) Emergency and disaster information including names, telephone numbers, evacuation routes, and fire equipment locations were not posted throughout the facility.
R432-270-26(3) Simulated fire drills were not conducted quarterly on each shift and documentation lacked resident evacuation ability, problems encountered, and time of drill.
R432-270-26(5) Extra blankets and a radio were not provided in-house for emergencies.
R432-270-27(4) Facility did not have an approved first aid manual.
R432-270-22(5) Flammable, poisonous, and hazardous materials were improperly stored in multiple facility locations including salon and restrooms.
R432-270-24(1)(b) Entrances, exits, and outside walkways were not maintained free of ice, snow, and hazards; a forced air space heater was running in resident room #125.
R432-270-24(4) Hot water temperature was too cold in the public restroom near resident room #130.
Report Facts
Number of rule noncompliances: 18
Residents with incomplete admission agreements: 6
Residents with incomplete emergency evacuation plans: 2
Residents without hospice care plans: 2
Residents without completed assessments prior to admission: 2
Residents with incomplete service plans: 3
Medication error incident reports: 3
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