Deficiencies (over last year)
Deficiencies (over last year)
24 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
204% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Routine
Deficiencies: 24
Date: Dec 13, 2023
Visit Reason
Routine unannounced inspection of Legacy House of Park Lane assisted living facility to assess compliance with licensing and regulatory requirements.
Findings
The facility was found to have multiple rule noncompliances totaling 22. Deficiencies were noted across various regulatory areas including personnel orientation, medication administration, resident rights, housekeeping, maintenance, emergency preparedness, and others. Some areas were fully compliant while others had minor to moderate deficiencies.
Deficiencies (24)
R432-270-9(7)(a)-(f) Two employees did not receive orientation within 30 days of hire including ethics, confidentiality, resident rights, abuse reporting, policies, and core competency.
R432-270-9(9)(a)-(l) Two employees did not complete all annual in-service trainings except dementia and Alzheimer's specific training.
R432-270-9(14)(a-g) One employee did not have record of tuberculosis screening in their file.
R432-270-10(2)(a)-(b) Resident assessment did not include information on hospice services; assessment included hospice through Hospice, not Hospice services.
R432-270-10(3)(a-b) Resident assessment showed one resident in Secure Unit had a significant change not reflected in the assessment.
R432-270-14(2) Resident service plans did not match resident assessment on medication administration frequency; assessment was not used to develop or revise service plan.
R432-270-15(2) Medication administration by type II assisted living licensee was not fully compliant with nursing service requirements.
R432-270-15(4) Nursing services provided by type I assisted living licensee were not fully compliant with policy requirements.
R432-270-19(7)(a-f) One resident did not receive their medications as ordered; medication administration delegation and supervision were deficient.
R432-270-19(16) QA meeting notes did not include report on medication errors for first and third quarter of 2023.
R432-270-21(2) Records with resident first and last names and room numbers were accessible in unlocked laundry room across from kitchen.
R432-270-23(5) Four containers of cleaning agents and poisonous materials were observed unlocked and accessible in multiple locations including Belmont Room, Discovery Room, and laundry areas.
R432-270-25(1) Two unsecured CO2 tanks were observed in kitchen dry storage area.
R432-270-26(8)(a)-(d) Fire drills did not include residents' ability to evacuate; no semi-annual disaster drills conducted.
R432-270-29(1) No respite services were offered at this time.
R432-270-30(1) Do not offer adult day care services.
R432-270-30(3)(a)-(e) Director did not have documentation of CPR and first aid training for two staff members working night shift.
R432-270-31(1) Director did not have documentation of CPR and first aid training for two staff members working night shift.
R432-270-31(2) Current edition of first aid manual was not available at specified location.
R432-270-31(6)(a) Resident funds over $150 were not deposited within five days in interest-bearing bank account.
R432-270-31(6)(b) Resident funds were not conveyed to resident or legal representative on day of discharge.
R432-270-31(6)(c) Resident funds were not accounted for within three working days after discharge.
R432-270-31(6)(d) Resident funds were not accounted for within three working days after death of resident.
R432-270-35-4(2)(a)-(b) No fingerprints for one employee within 15 days of hire; DACS did not reflect current status of two employees within 5 working days.
Report Facts
Number of rule noncompliances: 22
Containers of cleaning agents: 4
CO2 tanks: 2
Fingerprinting delay: 1
DACS status delay: 2
Staff without CPR/First Aid: 2
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