Deficiencies (over last year)
Deficiencies (over last year)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
1% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Renewal
Capacity: 152
Deficiencies: 8
Date: Oct 19, 2024
Visit Reason
The inspection was conducted as a re-licensure renewal for the assisted living facility to ensure compliance with state regulations and licensing requirements.
Findings
The inspection checklist reviewed multiple regulatory areas including identification badges, provider duties, administrator qualifications, personnel, resident rights, service plans, nursing services, medication administration, management of resident funds, and emergency preparedness. Several noncompliance issues were noted, particularly related to medication administration, resident assessments, and emergency preparedness.
Deficiencies (8)
R432-270-19(9) Home health care medication administration shall ensure licensed health care personnel administer medications to facility residents as prescribed. Nine out of ten medication errors did not have documentation when medication errors occurred.
R432-270-19(15) The licensee shall ensure that medication error incidents are recorded and reported for quality improvement. The medication room upstairs was left unlocked and unattended.
R432-270-25(4) The licensee shall ensure maintenance equipment is properly stored and maintained. Fire doors on the second floor near the salon and elevator did not close all the way.
R432-270-26(2)(a) The licensee shall ensure emergency and disaster plans are in place and staff are trained. Missing fire drills for the AM shift for the 1st and 3rd quarters of 2024 and PM shift for the 2nd quarter of 2024.
R432-270-28(2) The licensee shall ensure pets at the facility are kept disease-free and clean. Pets were not kept current on vaccinations and the facility did not have a procedure to prevent transmission of psittacosis.
R432-270-21(2) The licensee shall ensure accurate and complete records are maintained and accessible. There was no documentation of medication errors being discussed in QA meetings.
R432-270-19(16) The licensee shall ensure medication storage areas are secure and accessible only to authorized personnel. Medication room upstairs was left unlocked and unattended.
R432-270-26(3) The licensee shall ensure emergency and disaster plans include instructions on fire safety and evacuation. Missing fire drills for multiple quarters in 2024.
Report Facts
Licensed Capacity: 152
Number of medication errors documented: 9
Missing fire drills: 3
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