Deficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% better than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 29, 2024
Visit Reason
The inspection was conducted as part of a regulatory survey to assess compliance with nursing home regulations, including safety hazards and resident care.
Findings
The facility was found to have safety hazards related to unsecured chemicals in the laundry room and failed to provide appropriate bladder training care for a resident assessed as a likely candidate for such a program.
Deficiencies (2)
Laundry room was left open with no staff present, exposing residents to various hazardous chemicals.
Failure to provide appropriate treatment and services for a resident with urinary incontinence to restore continence to the extent possible.
Report Facts
Residents sampled: 37
Containers of Febreeze fabric refresher: 4
Containers of Comet disinfecting sanitizing bathroom cleaner: 7
Bottles of broad range quaternary sanitizer: 2
Containers of disinfecting all purpose spray and glass cleaner: 2
5 gallon containers of tide whiteness enhancer: 1
5 gallon containers of Tide laundry detergent: 1
5 gallon containers of Clorox bleach: 1
Boxes of tide stain removal treatment powder: 9
Bottles of tide rust stain remover: 6
One gallon containers of germicidal ultra bleach: 5
Brief Interview for Mental Status (BIMS) score: 15
Bowel and Bladder Evaluation score: 8
Episodes of urinary incontinence: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Interviewed regarding bowel and bladder evaluation and resident 10's care |
| Director of Nursing | Director of Nursing | Interviewed regarding bowel and bladder assessment and resident 10's candidacy for program |
| Maintenance Director | Maintenance Director | Interviewed regarding laundry room safety and chemical access |
| Housekeeping | Housekeeping Staff | Interviewed regarding laundry room door policy and resident access |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 29, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety and care, including accident hazard prevention and appropriate care for residents with urinary incontinence.
Findings
The facility failed to ensure the laundry room was secured to prevent resident access to hazardous chemicals, posing accident hazards. Additionally, the facility did not provide appropriate bladder training services to a resident identified as a likely candidate for such a program, resulting in inadequate care for urinary incontinence.
Deficiencies (2)
Laundry room was left open with no staff present, allowing resident access to various hazardous chemicals.
Failure to provide appropriate treatment and services for urinary incontinence to a resident assessed as a likely candidate for a toileting program.
Report Facts
Residents sampled: 37
Containers of Febreeze fabric refresher: 4
Containers of Comet disinfecting sanitizing bathroom cleaner: 7
Bottles of broad range quaternary sanitizer: 2
Containers of disinfecting all purpose spray and glass cleaner: 2
Gallons of tide whiteness enhancer: 5
Gallons of Tide laundry detergent: 5
Gallons of Clorox bleach: 5
Boxes of tide stain removal treatment powder: 9
Bottles of tide rust stain remover: 6
One gallon containers of germicidal ultra bleach: 5
Brief Interview for Mental Status (BIMS) score: 15
Bowel and Bladder Evaluation score: 8
Episodes of urinary incontinence: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Interviewed regarding bowel and bladder evaluation and resident 10's care |
| Director of Nursing | Director of Nursing | Interviewed regarding bowel and bladder assessment and resident 10's candidacy for toileting program |
| Maintenance Director | Maintenance Director | Interviewed regarding laundry room safety and chemical access |
| Housekeeping | Housekeeping Staff | Interviewed regarding laundry room door policy and resident access |
Inspection Report
Routine
Deficiencies: 13
Date: May 4, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, safety, abuse prevention, infection control, medication management, and laboratory services.
Findings
The facility was found deficient in multiple areas including timely completion of POLST forms, maintenance of a safe and clean environment, prevention and investigation of abuse, timely reporting of incidents, appropriate treatment and care, medication labeling and security, laboratory services and notification, infection prevention and control, and COVID-19 staff vaccination and testing compliance.
Deficiencies (13)
Residents' Physicians Orders for Life Sustaining Treatment (POLST) forms were not filled out timely after admission.
Facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; showers were in disrepair.
Residents were threatened by a roommate and there was no investigation to rule out abuse.
Facility did not timely report suspected abuse, neglect, or theft and did not report results of investigations within required timeframes.
Facility did not ensure all alleged abuse violations were thoroughly investigated.
Resident was not treated for a urinary tract infection as indicated by abnormal urine analysis and culture results.
Resident had access to hazardous chemicals and a hallway rug posed a tripping hazard; resident tripped on rug using walker.
Insulins were not labeled with an open date and medication cart was left unlocked when nurse was not present.
Facility did not obtain laboratory services timely as ordered for medical monitoring.
Facility did not promptly notify ordering practitioner of laboratory results that fell outside clinical reference ranges.
Facility did not establish and maintain an infection prevention and control program; lacked appropriate signage, PPE use, and visitor screening.
Facility did not conduct routine COVID-19 testing for unvaccinated staff as required by community transmission rates.
Facility did not ensure all staff were fully vaccinated for COVID-19 and did not implement policies for unvaccinated staff.
Report Facts
Days delay for POLST form completion: 84
Days delay for POLST form completion: 61
Residents sample size: 23
Residents affected: 2
Residents affected: 2
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 3
Staff members with religious objections: 5
Staff members without COVID-19 testing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Interviewed regarding POLST form completion and abuse incident |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding POLST form completion, abuse incidents, infection control, medication labeling, and lab services |
| CNA 2 | Certified Nursing Assistant | Reported abuse threats by resident 89 |
| CNA 3 | Certified Nursing Assistant | Reported abuse threats by resident 89 and interviewed about abuse incident |
| CRN 1 | Corporate Resource Nurse | Interviewed regarding abuse incident and lab services |
| Nurse Practitioner | Nurse Practitioner (NP) | Interviewed regarding abuse incident, lab services, and resident care |
| Operations Manager | Operations Manager (OM) | Interviewed regarding abuse incident, infection control, and COVID-19 testing |
| Maintenance Director | Maintenance Director (MD) | Interviewed regarding shower maintenance and infection control |
| Licensed Practical Nurse 1 | Licensed Practical Nurse (LPN) | Interviewed regarding resident 194 supervision and infection control |
| RN 2 | Registered Nurse | Observed leaving medication cart unlocked |
| RN 6 | Registered Nurse | Observed administering unlabeled insulin |
| Housekeeper 1 | Housekeeper | Interviewed regarding housekeeping closet access |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 7, 2019
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify physicians of abnormal blood glucose levels, medication availability issues, and discrepancies in narcotic administration documentation.
Complaint Details
The complaint investigation found that the facility did not notify the physician of abnormal blood glucose levels for resident 23, medications were not available for residents 13 and 25, and there were discrepancies between narcotic administration logs and MARs for residents 23 and 46.
Findings
The facility failed to notify the physician for one resident with abnormal blood glucose levels, did not have certain medications available for two residents, and had discrepancies between narcotic administration records and medication administration records for two residents.
Deficiencies (3)
Failure to notify the resident's physician of abnormal blood glucose levels for resident 23.
Failure to provide routine and emergency drugs and biologicals; medications not available for residents 13 and 25.
Inaccurate documentation of medical records; discrepancies between Medication Administration Records (MARs) and Narcotic Record Logs for residents 23 and 46.
Report Facts
Resident sample size: 23
Dates with blood glucose levels >400: 16
Medication administration discrepancies: 38
Medication administration discrepancies: 23
Medication administration discrepancies: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | LPN | Interviewed regarding medication administration and narcotic documentation |
| Licensed Practical Nurse 2 | LPN | Interviewed regarding medication ordering and narcotic documentation |
| Registered Nurse 1 | RN | Interviewed regarding adherence to physician orders and narcotic documentation |
| Director of Nursing | DON | Interviewed regarding staff education and medication administration policies |
| Corporate Resource Nurse | CRN | Interviewed regarding notification procedures for abnormal blood glucose levels |
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