Inspection Report
Annual Inspection
Capacity: 160
Deficiencies: 10
Jan 21, 2024
Visit Reason
The inspection was an announced annual inspection of the assisted living facility Legacy Village of Sugar House to assess compliance with state licensing rules and regulations.
Findings
The inspection identified nine rule noncompliances related to employee training, resident rights documentation, emergency preparedness, and other regulatory requirements. Several specific deficiencies were noted including incomplete core competency training for one employee, missing annual in-service training for four employees, incomplete resident rights notification, and incomplete emergency and disaster plans.
Deficiencies (10)
| Description |
|---|
| One employee did not have documented completion of core competency training. |
| Four employees had not completed documented annual in-service training. |
| One employee was not skin-tested for tuberculosis within two weeks of initial hire. |
| The written legal rights did not include a statement that the resident could file a complaint with the state long-term care ombudsman and any other advocacy group concerning resident abuse, neglect, or misappropriation of resident property in the facility. |
| One resident was not capable of evacuating the facility with the limited assistance of one person. |
| The admission agreements were missing a notice that the department had the authority to examine resident records to determine compliance with licensing requirements. |
| Dish soap was observed in the ice cream parlor under the sink and laundry stain remover, disinfectant bleach and fabric spray were found in the 6th floor laundry room. |
| The 5th floor memory care had carpet stain inhibitor bleach that was not labeled. |
| Emergencies and disasters did not include severe weather, explosion or windstorm. |
| The licensee did not ensure that emergency information was posted in public locations throughout the facility. |
Report Facts
Number of rule noncompliances: 9
Maximum Capacity: 160
Secured beds: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Miranda Moss | Administrator | Named as the designated administrator and individual informed of the inspection. |
Inspection Report
Annual Inspection
Capacity: 160
Deficiencies: 10
Jan 21, 2024
Visit Reason
The inspection was an announced annual inspection of the assisted living facility Legacy Village of Sugar House to assess compliance with state licensing rules and regulations.
Findings
The inspection identified nine rule noncompliances related to employee training, resident rights documentation, emergency preparedness, and other regulatory requirements. Several deficiencies were noted including incomplete core competency training for one employee, missing annual in-service training for four employees, incomplete resident admission agreements, and incomplete emergency and disaster plans.
Deficiencies (10)
| Description |
|---|
| One employee did not have documented completion of core competency training. |
| Four employees had not completed documented annual in-service training. |
| One employee was not skin-tested for tuberculosis within two weeks of initial hire. |
| The written legal rights did not include a statement that the resident could file a complaint with the state long-term care ombudsman and any other advocacy group concerning resident abuse, neglect, or misappropriation of resident property in the facility. |
| One resident was not capable of evacuating the facility with the limited assistance of one person. |
| The admission agreements were missing a notice that the department had the authority to examine resident records to determine compliance with licensing requirements. |
| Dish soap was observed in the ice cream parlor under the sink and laundry stain remover, disinfectant bleach and fabric spray were found in the 6th floor laundry room. |
| The 5th floor memory care had carpet stain inhibitor bleach that was not labeled. |
| Emergencies and disasters did not include severe weather, explosion or windstorm. |
| The licensee did not ensure that emergency information was posted in public locations throughout the facility. |
Report Facts
Number of rule noncompliances: 9
Maximum Capacity: 160
Secured beds: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Miranda Moss | Administrator | Named as the facility administrator and individual informed of the inspection. |
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