Deficiencies (over last year)
Deficiencies (over last year)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 9
Date: May 7, 2025
Visit Reason
The inspection was an unannounced routine compliance check of the Heritage Gardens assisted living facility.
Findings
The inspection identified 9 rule noncompliances related to staff training, medication administration, emergency preparedness, maintenance, and documentation. Several deficiencies were noted including missing fire and disaster drills, incomplete medication error reporting, and lack of resident fund management.
Deficiencies (9)
R432-270-9(9)(a)-(l) One employee did not receive documented annual in-service training in 2024, and the administrator did not complete required core competency training including Alzheimer's specific training.
R432-270-19(15) No medication error incident reports were completed for 2025 despite identified medication errors.
R432-270-25(1) Preventive maintenance was not being maintained according to the written schedule.
R432-270-26(8)(a)-(d) Missing fire drills for the prior 4 quarters and missing two documented disaster drills for the past year; employee participants not included in documentation.
R432-270-21(2) Records are not adequately protected against access by unauthorized individuals; medication change book with PHI was left unattended on top of medication cart.
R432-35-3(1) and (2) Two employees lacked required information in DACS for certification of direct patient access; one employee did not have a signed BCI authorization form.
Facility does not manage resident funds as required by multiple rules in Section 20.
R432-270-19(6)(a-c) Family members or designated responsible persons assisting with medication administration did not sign required waivers.
R432-270-19(7)(a-f) Facility staff administering medications did so without proper delegation and supervision by licensed health care professionals.
Report Facts
Rule noncompliances: 9
Employees lacking DACS certification info: 2
Employees lacking signed BCI form: 1
Missing fire drills: 4
Missing disaster drills: 2
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