Deficiencies (over last year)
Deficiencies (over last year)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 13
Date: May 6, 2024
Visit Reason
The inspection was an unannounced routine regulatory compliance check of Lotus Park Care Centers, an assisted living facility, conducted by Utah Department of Health & Human Services.
Findings
The inspection identified multiple deficiencies including missing designated administrator in writing, incomplete employee orientation and training, incomplete resident assessments and service plans, maintenance issues with exit lights and fire doors, and deficiencies in emergency and disaster preparedness plans. Several employees were not entered into the DACS system prior to hire and lacked required background checks.
Deficiencies (13)
The administrator did not have designated in writing a competent employee, 21 years or older, to act as administrator.
One employee did not have documented orientation within 30 days of hire.
Two new hire employees did not have documented 16 hours of one-on-one job training with a direct-care employee.
Four employees did not have all of the annual training and core competency training required by the rule.
One resident who was evicted did not have a signed 30-day notice on file in the facility.
One resident who was issued an eviction notice did not have documented a copy of the notice sent to the state long term care ombudsman.
Three resident assessments did not include memory.
Two resident assessments did not accurately reflect the resident's status at the time of the assessment.
At least one washing machine and clothes dryer was not made available for resident use.
Two exit lights are not working properly. The fire doors on the East hallway and the fire doors on the West hallway in the memory care have a 1/2 inch to 3/4 inch gap between them with no astricle device between the doors.
Emergency and disaster response plan did not include policies for missing residents, death of residents, and mass casualty.
Emergency and disaster response plan did not include assignment of personnel to specific tasks during an emergency; instructions on how to recruit additional help, supplies, and equipment; delivery of essential care and services 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 if personnel are reduced by an emergency.
Did not have 3 employees entered in DACS prior to hire. Did not have the criminal background authorization form for 7 individuals. Three employees did not have fingerprints taken within 15 working days of engagement.
Report Facts
Number of rule noncompliances: 15
Number of employees without criminal background authorization form: 7
Number of employees without fingerprints within 15 working days: 3
Number of employees not entered in DACS prior to hire: 3
Number of resident assessments missing memory component: 3
Number of resident assessments not accurately reflecting status: 2
Number of employees lacking documented orientation within 30 days: 1
Number of employees lacking documented 16 hours one-on-one training: 2
Number of employees lacking annual training and core competency: 4
Number of residents without signed 30-day eviction notice: 1
Loading inspection reports...



