Deficiencies (over last year)
Deficiencies (over last year)
46 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
482% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Routine
Deficiencies: 46
Date: Jun 4, 2025
Visit Reason
Routine inspection of an assisted living facility to review compliance with licensing regulations, resident care, safety, and administrative requirements.
Findings
The inspection covered multiple areas including resident rights, medication management, emergency preparedness, food services, housekeeping, and resident assessments. Several noncompliance issues were identified across various regulatory sections, with some requiring correction and follow-up.
Deficiencies (46)
R432-270-5(1)(a-b) The licensee shall ensure a person or family member is allowed to participate in the resident's care and activities. The facility did not fully ensure resident participation in care decisions.
R380.80-4(1) The provider shall protect each client from abuse, neglect, exploitation, and mistreatment. There were concerns about resident safety and protection.
R432-270-6(1)(a-g) The licensee shall ensure compliance with licensing requirements including admission, discharge, and resident rights. Documentation and procedures were incomplete or missing.
R432-270-7(1)(a-e) The administrator shall meet qualifications and provide oversight. The facility lacked a qualified administrator during the inspection.
R432-270-8(1)(a-d) The licensee shall maintain adequate staffing and personnel records. Staffing documentation was incomplete or inaccurate.
R432-270-9(1)(a-f) The licensee shall maintain personnel files including training and background checks. Files were incomplete or missing required documentation.
R432-270-10(1)(a-e) The licensee shall maintain resident rights including notification of discharge and grievance procedures. Some residents were not properly informed.
R432-270-11(1)(a-e) The licensee shall maintain admission and discharge policies and procedures. Documentation was incomplete or not followed.
R432-270-12(1)(a-e) The licensee shall maintain transfer and discharge procedures including notification and documentation. Procedures were not consistently followed.
R432-270-13(1)(a-b) The licensee shall conduct resident assessments including admission and ongoing evaluations. Assessments were incomplete or missing.
R432-270-14(1)(a-e) The licensee shall maintain service plans reflecting resident needs and preferences. Service plans were incomplete or not updated.
R432-270-15(1)(a-d) The licensee shall maintain nursing services including medication administration and documentation. Medication records were incomplete or inaccurate.
R432-270-16(1)(a-b) The licensee shall maintain secure units with controlled access and documentation. Security measures were insufficient.
R432-270-17(1)(a-h) The licensee shall provide medical and dental care including access to licensed professionals and emergency services. Documentation and access were inadequate.
R432-270-18(1)(a-e) The licensee shall maintain activity programs including schedules and resident participation. Activity documentation was incomplete.
R432-270-19(1)(a-g) The licensee shall maintain medication administration records and ensure staff competency. Medication errors and documentation issues were noted.
R432-270-20(1)(a-b) The licensee shall manage resident funds with proper accounting and documentation. Financial records were incomplete or inaccurate.
R432-270-21(1)(a-d) The licensee shall maintain resident records including financial and medical information. Records were incomplete or missing.
R432-270-22(1)(a-d) The licensee shall maintain food services including menus, food safety, and resident preferences. Food service documentation was incomplete.
R432-270-23(1)(a-e) The licensee shall maintain housekeeping services including cleaning schedules and sanitation. Housekeeping documentation was incomplete.
R432-270-24(1)(a-d) The licensee shall maintain laundry services including cleaning and maintenance of linens. Laundry services were inadequate.
R432-270-25(1)(a-c) The licensee shall maintain maintenance services including equipment and safety. Maintenance records were incomplete.
R432-270-26(1)(a-d) The licensee shall maintain disaster and emergency preparedness including plans and staff training. Emergency plans were incomplete or not followed.
R432-270-28(1)(a-c) The licensee shall maintain pet policies including care and sanitation. Facility does not have pets.
R432-270-29(1)(a-b) The licensee shall maintain respite services including admission and discharge policies. Facility does not provide respite services.
R432-270-30(1)(a-e) The licensee shall maintain adult day care services including admission, assessments, and service plans. Facility does not provide adult day care.
R432-270-31(1)(a-e) The licensee shall maintain penalties and enforcement procedures. Penalties were noted for failure to comply with regulations.
R432-270-32(1)(a-c) The licensee shall maintain covered provider procedures including access and documentation. Some access and documentation issues were noted.
R432-270-33(1)(a-c) The licensee shall maintain covered provider-DACS process including documentation and staff training. Documentation was incomplete.
R432-270-34(1)(a-c) The licensee shall maintain covered provider-DACS process including background checks and staff qualifications. Documentation was incomplete.
R432-270-35(1)(a-b) The licensee shall maintain covered provider-DACS process including staff supervision and training. Documentation was incomplete.
R432-270-36(1)(a-g) The licensee shall maintain covered provider-DACS process including medication administration and documentation. Documentation was incomplete.
R432-270-37(1)(a-c) The licensee shall maintain covered provider-DACS process including emergency preparedness and staff training. Documentation was incomplete.
R432-270-38(1)(a-c) The licensee shall maintain covered provider-DACS process including incident reporting and staff training. Documentation was incomplete.
R432-270-39(1)(a-d) The licensee shall maintain covered provider-DACS process including staff training and supervision. Documentation was incomplete.
R432-270-40(1)(a-c) The licensee shall maintain covered provider-DACS process including staff training and supervision. Documentation was incomplete.
R432-270-41(1)(a-c) The licensee shall maintain covered provider-DACS process including staff training and supervision. Documentation was incomplete.
R432-270-42(1)(a-c) The licensee shall maintain covered provider-DACS process including staff training and supervision. Documentation was incomplete.
R432-270-43(1)(a-c) The licensee shall maintain covered provider-DACS process including staff training and supervision. Documentation was incomplete.
R432-270-44(1)(a-c) The licensee shall maintain covered provider-DACS process including staff training and supervision. Documentation was incomplete.
R432-270-45(1)(a-c) The licensee shall maintain covered provider-DACS process including staff training and supervision. Documentation was incomplete.
R432-270-46(1)(a-c) The licensee shall maintain covered provider-DACS process including staff training and supervision. Documentation was incomplete.
R432-270-47(1)(a-c) The licensee shall maintain covered provider-DACS process including staff training and supervision. Documentation was incomplete.
R432-270-48(1)(a-c) The licensee shall maintain covered provider-DACS process including staff training and supervision. Documentation was incomplete.
R432-270-49(1)(a-c) The licensee shall maintain covered provider-DACS process including staff training and supervision. Documentation was incomplete.
R432-270-50(1)(a-c) The licensee shall maintain covered provider-DACS process including staff training and supervision. Documentation was incomplete.
Report Facts
Deficiencies cited: 141
Deficiencies cited: 10
Deficiencies cited: 53
Deficiencies cited: 8
Deficiencies cited: 2
Deficiencies cited: 206
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