Deficiencies (over last year)
Deficiencies (over last year)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
39% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 11
Date: Oct 7, 2024
Visit Reason
Unannounced routine inspection conducted to assess compliance with assisted living facility regulations and licensing requirements.
Findings
The inspection identified 18 rule noncompliances across various regulatory areas including quality assurance, employee training, resident care, medication administration, fire drills, pet vaccinations, and maintenance. Several deficiencies were noted related to staff orientation, in-service training, medication delegation, fire drill documentation, and facility safety measures.
Deficiencies (11)
R432-270-6(2) The quality assurance committee did not meet during the 3rd quarter of 2024 and the 4th quarter of 2023.
R432-270-9(7) Three employees did not receive documented orientation to the facility for their hired position and did not have a department approved core competency training.
R432-270-9(9) Five employees did not have documented in-service training in subjects relevant to the employees job responsibilities.
R432-270-9(10) One administrator does not have a minimum of four hours of core competency training that includes dementia and Alzheimer's specific training.
R432-270-9(14) One employee did not have an employee health inventory completed when hired and one employee was not skin tested for tuberculosis within 2 weeks of hire.
R432-270-22(5) The licensee did not ensure locked storage for potentially dangerous items such as scissors, knives, and toxic materials; scissors were found in the kitchenette drawer on the second floor.
R432-270-25(1) Maintenance, including preventive maintenance, was not conducted according to a written schedule; two CO2 tanks in the kitchen were not secured.
R432-270-26(8) Missing fire drills for AM and Grave shifts for 2nd quarter of 2024 and missing fire drills for 3rd quarter of 2024.
R432-270-28(6) The facility was not able to provide vaccinations for 5 pets.
R432-270-19(7) One employee was not delegated by a licensed health care professional to administer medication to residents.
R432-35-4(2) Two employees did not sign a criminal background screening authorization form that was available for review by the department.
Report Facts
Rule noncompliances: 18
Missing fire drills: 3
Pets without vaccinations: 5
Employees without documented orientation: 3
Employees without in-service training: 5
Employees without signed background screening: 2
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