Deficiencies (over last year)
Deficiencies (over last year)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
39% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 11
Date: Nov 29, 2023
Visit Reason
Unannounced routine inspection to review compliance with assisted living facility regulations and licensing requirements.
Findings
The inspection identified 14 rule noncompliances including deficiencies in emergency evacuation planning, medication administration records, employee training, and maintenance issues such as unsecured oxygen tanks and fire door malfunctions. Several administrative and procedural deficiencies were also noted, including incomplete personnel records and missing emergency plans.
Deficiencies (11)
The secured unit did not have an emergency evacuation plan that addressed the ability of the secure unit staff to evacuate residents in case of emergency.
An emergency evacuation plan was not accurate for a hospice resident.
Assessments for 4 residents were not signed and dated by a licensed health care professional.
A resident assessment was not accurate and was not updated or revised when a significant change occurred.
A resident required a transfer pole and assistance with compression socks that were not assessed or included in the service plan.
The licensee did not maintain an accurate medication administration record for a resident.
Two unsecured oxygen tanks were found in Resident Room MC172. One fire door next to Resident Room MC175 did not close and latch. The electrical room entrance was open and accessible with five electrical boxes open and accessible.
The licensee reviewed the Disaster Plan and requested the missing emergency plans from the Administrator. Emergency plans were not provided that met the rule.
Criminal background screening authorization forms were not completed for 3 employees and 4 employees did not submit fingerprints within 15 days of hire.
Seven employees were missing some of the annual in-service trainings. An annual in-service on core competency was not done in the facility.
Two employees did not have health inventories in their files.
Report Facts
Number of rule noncompliances: 14
Employees missing fingerprints: 4
Employees missing background screening forms: 3
Employees missing annual in-service trainings: 7
Residents with unsigned assessments: 4
Deficiency count: 14
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