Deficiencies (over last year)
Deficiencies (over last year)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 15
Date: Jan 16, 2024
Visit Reason
Unannounced routine inspection of Legacy Village of Provo assisted living facility to assess compliance with state regulations.
Findings
The inspection identified multiple areas of noncompliance including deficiencies in employee orientation, training, medication administration, emergency preparedness, housekeeping, maintenance, and documentation. Several regulatory requirements were not met, such as missing fire drills, unlocked employee records, and incomplete personnel files.
Deficiencies (15)
Four employees lacked documentation of completed orientation within 30 days of hire.
One employee lacked documentation of 16 hours of one-on-one job training.
Four employees did not have documented in-service training relevant to their job responsibilities.
Four employees did not have timely tuberculosis skin tests; one test was administered late and two employees lacked health inventories.
The secure unit lacked an emergency evacuation plan addressing evacuation by staff.
Two employees did not have current Food Handler's permits.
Chaffing dish fuel, paint, glass cleaner, all-purpose cleaner, spray carpet cleaner, hand sanitizer, and joint compound were improperly stored or accessible.
Two fire-rated doors in the secure unit were propped open; inspection certificates were unavailable for review.
The facility's emergency and disaster plan lacked instructions on recruiting additional help, delivering essential care by alternate means, and managing care if personnel are reduced during emergencies.
Third quarter fire drills were not conducted for any of the three shifts.
Required emergency contact information was not posted in public locations throughout the facility.
The copy room was unlocked with employee records accessible in an unlocked cabinet.
Two terminated employees lacked termination dates in personnel files; one lacked documentation of initial core competency; five personnel files lacked employee applications.
Four employees were not linked to the facility in the Department of Administrative and Criminal Background Screening (DACS) system.
The admission agreement did not include a notice that the department has authority to examine resident records for licensing compliance.
Report Facts
Rule noncompliances: 15
Employees lacking orientation documentation: 4
Employees lacking one-on-one training documentation: 1
Employees lacking in-service training documentation: 4
Employees lacking TB tests or health inventories: 7
Employees lacking Food Handler's permits: 2
Terminated employees missing termination dates: 2
Personnel files missing employee applications: 5
Employees not linked in DACS: 4
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