Inspection Report
Routine
Deficiencies: 17
Nov 13, 2023
Visit Reason
The inspection was an unannounced routine inspection of the Legacy House of Ogden assisted living facility to assess compliance with state regulations and licensing requirements.
Findings
The inspection checklist revealed 17 rule noncompliances across various regulatory areas including personnel orientation, administrator duties, medication administration, emergency preparedness, and facility maintenance. Some deficiencies were corrected during the inspection, while others had compliance required by specified dates.
Deficiencies (17)
| Description |
|---|
| Failure to complete documented orientation for each employee within 30 days of hire including job description, ethics, confidentiality, residents' rights, fire and disaster plan, policy and procedures, reporting responsibility for abuse, neglect and exploitation, and Department-approved core competency training. |
| Failure to provide documented one-on-one job training for direct-care employees with at least 3 months experience or supervising nurse at the facility. |
| Failure to complete employee skin testing by Mantoux Method or other FDA approved in-vitro serologic test and follow up for tuberculosis as required. |
| Failure to maintain a quality assurance program including a Quality Assurance Committee meeting at least quarterly. |
| Failure to complete investigation whenever there is reason to believe a resident has been subject to abuse, neglect, or exploitation by the compliance required date. |
| Failure to complete documented core competency training annually including dementia and Alzheimer's specific training. |
| Failure to maintain a current edition of a basic first aid manual approved by a recognized health agency. |
| Failure to maintain fire and disaster drills semi-annually and quarterly with documentation including date, participants, problems encountered, and ability of each resident to evacuate. |
| Failure to maintain emergency and disaster response plans including staff responsibilities and training. |
| Failure to maintain maintenance and housekeeping standards including pest control, hot water temperature, and housekeeping staff training. |
| Failure to maintain medication administration policies including documentation, review, and error reporting. |
| Failure to maintain resident records including admission agreements, assessments, and service plans. |
| Failure to maintain food service standards including menu approval, food safety, and food handler permits. |
| Failure to maintain laundry and housekeeping services including policies and cleanliness. |
| Failure to maintain secure storage for dangerous items and controlled substances. |
| Failure to maintain emergency evacuation plans for secure units and staff training. |
| Failure to maintain required documentation and certification for direct patient access covered providers. |
Report Facts
Rule noncompliances: 17
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