Inspection Reports for
Legacy House Assisted Living of South Jordan
1517 West Temple Lane, South Jordan, UT, 84095
Back to Facility ProfileDeficiencies (over last year)
Deficiencies (over last year)
21 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
166% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Routine
Deficiencies: 21
Date: Jan 27, 2025
Visit Reason
The inspection was an unannounced routine regulatory compliance check of Legacy House of South Jordan assisted living facility.
Findings
The inspection identified multiple rule noncompliances across various regulatory areas including personnel records, medication administration, emergency preparedness, housekeeping, and resident rights. Several deficiencies were noted related to staff training, documentation, emergency plans, and facility maintenance.
Deficiencies (21)
R432-1-4 Identification Badges: One employee was not wearing an identification badge as required.
R432-270-9(5) Personnel: One employee did not have an updated job description.
R432-270-9(9) Personnel: Three employees did not receive all their required annual in-service trainings.
R432-270-9(14) Personnel: One employee did not have a tuberculosis skin-test as required.
R432-270-10(2)(a)-(b) Residents' Rights: Resident legal rights documentation did not include a statement about filing complaints with the state long-term care ombudsman or advocacy groups.
R432-270-11(8)(a)-(g) Admissions: Resident admission agreement did not include notice that the department has authority to examine resident records for licensing compliance.
R432-270-14(2) Service Plan: Two resident assessments were not used to develop their service plans.
R432-270-16(3) Secure Units: Two direct-care employees lacked documented one-on-one training hours required for secure unit staff.
R432-270-21(3)(a)-(j) Records: Two terminated employee files did not have all required records.
R432-270-21(4)(a-e) Records: One resident file did not include the emergency room dentist contact information.
R432-270-22(3)(a)-(d) Food Services: No menu was posted for resident viewing and the substitution log was not maintained.
R432-270-23(5) Housekeeping: Cleaning agents and potentially hazardous materials were stored in unlocked areas accessible to residents.
R432-270-25(1) Maintenance: Electrical panels near the reception desk were unlocked.
R432-270-25(5) Maintenance: Water temperature was 130.8 degrees Fahrenheit, exceeding the allowed maximum.
R432-270-26(2)(a)-(c) Disaster Preparedness: Emergency and disaster response plan was not developed or coordinated with state and local authorities.
R432-270-26(4)(a-k) Disaster Preparedness: Emergency plan did not include provisions for severe weather, explosion, windstorm, or epidemic.
R432-270-26(8)(a)-(d) Disaster Preparedness: The licensee did not hold simulated fire drills quarterly on each shift as required.
R432-270-26(10)(b) Disaster Preparedness: The licensee did not have emergency heating.
R432-270-26(11)(a)-(b) Disaster Preparedness: Emergency contact information and evacuation routes were not posted in public areas.
R432-35-4(2)(a)-(b) Covered Provider - DACS Process: One employee had not submitted fingerprints within 15 working days of engagement.
R432-35-4(3) Covered Provider - DACS Process: One employee was not connected to DACS within 5 working days.
Report Facts
Rule noncompliances: 22
Employees without fingerprints within 15 days: 1
Employees not connected to DACS within 5 days: 1
Terminated employee files missing records: 2
Employees missing required annual in-services: 3
Employees missing secure unit training hours: 2
Resident assessments not used for service plans: 2
Water temperature: 130.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employees referenced in findings related to fingerprint submission and DACS connection. |
Report
January 27, 2025
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