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Inspection Reports for Aspen Ridge Residences of Lehi

564 West Main Street, Lehi, UT, 84043

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Inspection Report Summary

The most recent inspection on October 30, 2023, identified multiple deficiencies related to personnel training, resident assessments, service plans, medication administration, emergency preparedness, housekeeping, and facility records. Earlier inspections were not available for comparison, so the broader inspection pattern cannot be determined. Inspectors cited issues such as incomplete staff orientation, missing or incomplete resident care and emergency plans, medication errors, inadequate emergency drills, and safety concerns including improper storage of hazardous materials and incorrect water temperature. No complaint investigations or enforcement actions were listed in the available reports. Without prior reports, it is unclear whether these findings represent a trend or isolated issues.

Deficiencies (last 1 years)

Deficiencies (over 1 years) 15 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

90% worse than Utah average
Utah average: 7.9 deficiencies/year

Deficiencies per year

16 12 8 4 0
2023
Unclassified
State average

Inspection Report

Original Licensing
Deficiencies: 15 Date: Oct 30, 2023
Visit Reason
The inspection was an initial, unannounced licensing inspection of Aspen Ridge Residences of Lehi to ensure compliance with assisted living facility regulations.
Findings
The inspection identified 18 rule noncompliances across various regulatory areas including personnel training, resident assessments, service plans, medication administration, emergency preparedness, housekeeping, and facility records. Several deficiencies were noted with documentation, staff training, resident care plans, medication errors, emergency drills, and safety hazards such as improper storage of poisonous materials and inadequate hot water temperature.
Deficiencies (15)
Five employees did not receive documented orientation training within 30 days of hire including ethics, confidentiality, resident rights, fire and disaster plan, policy and procedures, reporting responsibility for abuse, neglect and exploitation, and core competency training.
Two residents' emergency evacuation plans were not incorporated into their service plans and two residents did not have hospice care plans.
Six resident admission agreements did not specify refund provisions addressing thirty-day notices, emergency transfers or discharges, and the death of a resident.
Two residents assessments were not completed prior to admission.
Four resident assessments did not include a statement that the resident met the admission and level of assistance criteria for the facility.
Two residents did not have the service plan developed within 7 days from the admission.
Three resident service plans did not specify who would provide services and how frequently the services would be provided.
One resident did not receive medication as prescribed.
RN was not notified when a medication error occurred for one medication not being available; medication technician did not complete a medication error incident report at the time of the error; three medication error reports were completed on the day of inspection.
Water temperature was too cold in the public restroom next to resident room #130.
Flammable materials were observed in the salon; poisonous materials were observed in the second floor public restroom by the activity director office and in cabinets next to the activity director office; chemicals were observed in the first floor restrooms and ice cream parlor.
Simulated fire drills were not conducted quarterly on each shift; documented fire drill did not include resident evacuation ability, problems encountered, or time of drill.
Extra blankets and a radio were not provided in-house for emergency preparedness.
Emergency and disaster response information was not posted throughout the facility.
Facility did not have an approved first aid manual.
Report Facts
Number of rule noncompliances: 18 Resident admission agreements: 6 Residents emergency evacuation plans: 2 Residents without hospice care plans: 2 Residents assessments not completed prior to admission: 2 Resident service plans lacking provider and frequency info: 3 Medication error reports: 3 Square feet per consumer: 50

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