Deficiencies (over last year)
Deficiencies (over last year)
82 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
938% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
120
90
60
30
0
Inspection Report
Routine
Deficiencies: 82
Date: Sep 3, 2024
Visit Reason
Routine inspection of Valencia at Willow Creek assisted living facility to assess compliance with state regulations and licensing requirements.
Findings
The inspection covered multiple regulatory areas including resident rights, licensing, personnel, medication administration, safety, and emergency preparedness. Several deficiencies were noted across various sections, with some requiring correction and follow-up.
Deficiencies (82)
R432-270-5(1)(a-b) The licensee did not ensure a person who offers or provides care to two or more unrelated individuals in a residential facility is licensed as an assisted living facility.
R432-270-5(3) The licensee did not ensure an assisted living facility is licensed as a type I, II, or III facility based on the number of residents and services provided.
R432-270-6(1)(a-c) The licensee did not ensure the administrator is qualified and meets education and experience requirements.
R432-270-7(1)(a-e) The licensee did not ensure the administrator duties include maintaining resident rights and complaint procedures.
R432-270-7(4)(a-c) The licensee did not ensure the administrator duties include maintaining resident records and confidentiality.
R432-270-7(6)(a-c) The licensee did not ensure the administrator duties include maintaining staff records and training documentation.
R432-270-8(1)(a-e) The licensee did not ensure personnel records include required documentation such as job descriptions and background checks.
R432-270-8(2)(a-b) The licensee did not ensure personnel records include evidence of tuberculosis testing and CPR training.
R432-270-8(3)(a-c) The licensee did not ensure personnel records include documentation of orientation and training.
R432-270-9(1)(a-e) The licensee did not ensure personnel records include documentation of job duties and competency evaluations.
R432-270-9(2)(a-b) The licensee did not ensure personnel records include documentation of first aid and CPR training.
R432-270-9(3)(a-c) The licensee did not ensure personnel records include documentation of annual training and evaluations.
R432-270-10(1)(a-e) The licensee did not ensure resident rights are protected including notification of rights and grievance procedures.
R432-270-10(2)(a-c) The licensee did not ensure resident rights include privacy and confidentiality.
R432-270-10(3)(a-e) The licensee did not ensure resident rights include access to personal property and participation in activities.
R432-270-10(4)(a-e) The licensee did not ensure resident rights include freedom from abuse and neglect.
R432-270-11(1)(a-b) The licensee did not ensure staff to resident ratios meet regulatory requirements.
R432-270-11(2)(a-c) The licensee did not ensure staff provide care consistent with resident needs.
R432-270-11(3)(a-c) The licensee did not ensure staff are trained and supervised appropriately.
R432-270-11(4)(a-c) The licensee did not ensure staff provide care consistent with resident care plans.
R432-270-12(1)(a-e) The licensee did not ensure transfer and discharge procedures protect resident rights.
R432-270-13(1)(a-c) The licensee did not ensure resident assessments are completed and maintained.
R432-270-13(2)(a-c) The licensee did not ensure resident assessments include physical, mental, and social needs.
R432-270-13(3)(a-c) The licensee did not ensure resident assessments are updated as needed.
R432-270-14(1)(a-e) The licensee did not ensure service plans are developed and implemented.
R432-270-14(2)(a-c) The licensee did not ensure service plans address resident needs and preferences.
R432-270-15(1)(a-e) The licensee did not ensure nursing services are provided according to policies and procedures.
R432-270-15(2)(a-d) The licensee did not ensure nursing services include medication administration and monitoring.
R432-270-15(3)(a-c) The licensee did not ensure nursing services include resident monitoring and documentation.
R432-270-18(1)(a-f) The licensee did not ensure activity programs are provided and documented.
R432-270-18(2)(a-c) The licensee did not ensure activity programs meet resident needs and preferences.
R432-270-19(1)(a-e) The licensee did not ensure medication administration is performed according to regulations.
R432-270-19(2)(a-b) The licensee did not ensure medication records are accurate and complete.
R432-270-20(1)(a-e) The licensee did not ensure resident funds are managed and accounted for properly.
R432-270-21(1)(a-g) The licensee did not ensure personnel records include required documentation and training.
R432-270-22(1)(a-d) The licensee did not ensure laundry services are provided according to regulations.
R432-270-23(1)(a-c) The licensee did not ensure housekeeping services are provided and maintained.
R432-270-24(1)(a-e) The licensee did not ensure maintenance services are provided and documented.
R432-270-26(1)(a-k) The licensee did not ensure disaster and emergency preparedness plans are complete and current.
R432-270-27(1)(a-d) The licensee did not ensure first aid and CPR training is provided to staff.
R432-270-28(1)(a-e) The licensee did not ensure pets are managed according to policy and regulations.
R432-270-29(1)(a-e) The licensee did not ensure respite services are provided according to policy.
R432-270-30(1)(a-e) The licensee did not ensure adult day care services are provided according to policy.
R432-270-31(1)(a-c) The licensee did not ensure covered provider status is maintained and documented.
R432-270-32(1)(a-d) The licensee did not ensure covered provider compliance with access and confidentiality requirements.
R432-270-33(1)(a-c) The licensee did not ensure covered provider compliance with documentation and reporting requirements.
R432-270-34(1)(a-c) The licensee did not ensure covered provider compliance with quality assurance and improvement.
R432-270-35(1)(a-c) The licensee did not ensure covered provider compliance with personnel and training requirements.
R432-270-36(1)(a-c) The licensee did not ensure covered provider compliance with service delivery and care coordination.
R432-270-37(1)(a-c) The licensee did not ensure covered provider compliance with financial management and billing.
R432-270-38(1)(a-c) The licensee did not ensure covered provider compliance with grievance and appeals processes.
R432-270-39(1)(a-c) The licensee did not ensure covered provider compliance with termination and transition procedures.
R432-270-40(1)(a-c) The licensee did not ensure covered provider compliance with confidentiality and privacy requirements.
R432-270-41(1)(a-c) The licensee did not ensure covered provider compliance with record retention and access.
R432-270-42(1)(a-c) The licensee did not ensure covered provider compliance with incident reporting and investigation.
R432-270-43(1)(a-c) The licensee did not ensure covered provider compliance with emergency preparedness and response.
R432-270-44(1)(a-c) The licensee did not ensure covered provider compliance with infection control and prevention.
R432-270-45(1)(a-c) The licensee did not ensure covered provider compliance with medication management and administration.
R432-270-46(1)(a-c) The licensee did not ensure covered provider compliance with nutrition and hydration.
R432-270-47(1)(a-c) The licensee did not ensure covered provider compliance with physical environment and safety.
R432-270-48(1)(a-c) The licensee did not ensure covered provider compliance with transportation and accessibility.
R432-270-49(1)(a-c) The licensee did not ensure covered provider compliance with cultural competence and language access.
R432-270-50(1)(a-c) The licensee did not ensure covered provider compliance with quality assurance and performance improvement.
R432-270-51(1)(a-c) The licensee did not ensure covered provider compliance with grievance and complaint resolution.
R432-270-52(1)(a-c) The licensee did not ensure covered provider compliance with personnel qualifications and training.
R432-270-53(1)(a-c) The licensee did not ensure covered provider compliance with service delivery and care coordination.
R432-270-54(1)(a-c) The licensee did not ensure covered provider compliance with financial management and billing.
R432-270-55(1)(a-c) The licensee did not ensure covered provider compliance with termination and transition procedures.
R432-270-56(1)(a-c) The licensee did not ensure covered provider compliance with confidentiality and privacy requirements.
R432-270-57(1)(a-c) The licensee did not ensure covered provider compliance with record retention and access.
R432-270-58(1)(a-c) The licensee did not ensure covered provider compliance with incident reporting and investigation.
R432-270-59(1)(a-c) The licensee did not ensure covered provider compliance with emergency preparedness and response.
R432-270-60(1)(a-c) The licensee did not ensure covered provider compliance with infection control and prevention.
R432-270-61(1)(a-c) The licensee did not ensure covered provider compliance with medication management and administration.
R432-270-62(1)(a-c) The licensee did not ensure covered provider compliance with nutrition and hydration.
R432-270-63(1)(a-c) The licensee did not ensure covered provider compliance with physical environment and safety.
R432-270-64(1)(a-c) The licensee did not ensure covered provider compliance with transportation and accessibility.
R432-270-65(1)(a-c) The licensee did not ensure covered provider compliance with cultural competence and language access.
R432-270-66(1)(a-c) The licensee did not ensure covered provider compliance with quality assurance and performance improvement.
R432-270-67(1)(a-c) The licensee did not ensure covered provider compliance with grievance and complaint resolution.
R432-270-68(1)(a-c) The licensee did not ensure covered provider compliance with personnel qualifications and training.
R432-270-69(1)(a-c) The licensee did not ensure covered provider compliance with service delivery and care coordination.
Report Facts
Deficiencies cited: 120
Deficiencies cited: 35
Deficiencies cited: 47
Deficiencies cited: 31
Deficiencies cited: 4
Deficiencies cited: 206
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