Deficiencies per Year
16
12
8
4
0
Unclassified
Inspection Report
Routine
Deficiencies: 14
Jan 16, 2024
Visit Reason
The inspection was an unannounced routine regulatory compliance inspection of the assisted living facility Legacy Village of Provo to assess compliance with state licensing rules.
Findings
The inspection identified 15 rule noncompliances across various regulatory areas including employee orientation and training, emergency preparedness, maintenance, housekeeping, and medication administration. Several deficiencies were corrected during the inspection, while others required follow-up.
Deficiencies (14)
| Description |
|---|
| 4 employees did not have documentation of completed orientation. |
| 1 employee did not have documentation of 16 hours of one-to-one job training. |
| 4 employees did not have documented in-service training. |
| 4 employees do not have TB tests; 1 employee TB test was administered late; 2 employees did not have health inventories. |
| Did not include in the admission agreement a notice that the department has the authority to examine resident records to determine compliance with licensing requirements. |
| Secure Unit did not have an emergency evacuation plan. |
| 2 employees did not have current Food Handler's permits. |
| Copy room was unlocked and employee records were accessible in an unlocked cabinet. |
| 2 termed employees did not have termination date in their personnel files; 1 termed employee did not have documentation of initial core competency; five personnel files did not include an employee application. |
| Two fire-rated doors in the secure unit were propped open and was corrected on site. The facility did not have the inspection certificates available for review. |
| The facility's emergency and disaster plan did not include instructions on how to recruit additional help, supplies, and equipment to meet residents' needs after an emergency or disaster; delivery of essential care and services to facility occupants by alternate means; delivery of essential care and services if additional persons are housed in the facility during an emergency; and delivery of essential care and services to facility occupants if personnel are reduced by an emergency. |
| Did not have 3rd quarter fire drills for any of the 3 shifts. |
| Did not observe required emergency contact information posted in public locations throughout the facility. |
| 4 employees not linked to facility in DACS. |
Report Facts
Number of rule noncompliances: 15
Deficiencies count: 15
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