Deficiencies (over last year)
Deficiencies (over last year)
18 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
128% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Capacity: 160
Deficiencies: 9
Date: Jan 21, 2024
Visit Reason
Annual announced inspection of Legacy Village of Sugar House assisted living facility to assess compliance with state regulations and licensing requirements.
Findings
The inspection identified nine rule noncompliances related to staff training, resident rights documentation, emergency preparedness, housekeeping, and medication administration. Several policies and procedures were found incomplete or missing required elements.
Deficiencies (9)
R432-270-9(7)(a)-(f) One employee did not have documented completion of core competency training within 30 days of hire.
R432-270-9(9)(a)-(l) Four employees had not completed documented annual in-service training relevant to their job responsibilities.
R432-270-9(14)(a)-(g) One employee was not skin-tested for tuberculosis within two weeks of initial hire.
R432-270-10(2)(a)-(b) The written legal rights did not include a statement that residents could file complaints with the state long-term care ombudsman and other advocacy groups.
R432-270-11(5)(a)-(c) One resident was not capable of evacuating the facility with the limited assistance of one person.
R432-270-11(8)(a)-(g) Admission agreements were missing a notice that the department has authority to examine resident records to determine licensing compliance.
R432-270-22(5) 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.
R432-270-26(4)(a)-(k) Emergencies and disasters plan did not include severe weather, explosion, or windstorm.
R432-270-26(11)(a)-(b) Emergency information was not posted in public locations throughout the facility.
Report Facts
Number of rule noncompliances: 9
Inspection Report
Annual Inspection
Capacity: 160
Deficiencies: 9
Date: Jan 21, 2024
Visit Reason
Annual announced inspection of Legacy Village of Sugar House assisted living facility to assess compliance with state regulations.
Findings
The inspection identified nine rule noncompliances including issues with employee training documentation, resident rights notification, emergency preparedness, and housekeeping chemical storage. Several policies and procedures were found lacking or incomplete.
Deficiencies (9)
R432-270-9(7)(a)-(f) One employee did not have documented completion of core competency training within 30 days of hire.
R432-270-9(9)(a)-(l) Four employees had not completed documented annual in-service training relevant to their job responsibilities.
R432-270-9(14)(a)-(g) One employee was not skin-tested for tuberculosis within two weeks of initial hire.
R432-270-10(2)(a)-(b) The written legal rights did not include a statement that residents could file complaints with the state long-term care ombudsman and other advocacy groups.
R432-270-11(5)(a)-(c) One resident was not capable of evacuating the facility with the limited assistance of one person as required for type II facilities.
R432-270-11(8)(a)-(g) The admission agreements were missing a notice that the department has authority to examine resident records to determine licensing compliance.
R432-270-22(5) Cleaning agents, bleaches, insecticides, or poisonous materials were stored in unlocked areas accessible to residents.
R432-270-26(4)(a)-(k) The emergency and disaster plan did not include severe weather, explosion, or windstorm as potential emergencies.
R432-270-26(11)(a)-(b) The licensee did not ensure that emergency information was posted in public locations throughout the facility.
Report Facts
Number of rule noncompliances: 9
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