Inspection Reports for
Maple Springs of North Logan
350 E 2200 N, North Logan, UT 84341, United States, UT, 84341
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
11% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Deficiencies: 1
Date: Dec 8, 2025
Visit Reason
The inspection was conducted following an incident involving a resident choking and passing away due to receiving food inconsistent with their prescribed diet texture. The visit reviewed the facility's compliance with dietary and safety regulations.
Findings
The facility failed to provide a resident with a diet that met their prescribed moist and minced texture, resulting in choking and death. The facility implemented corrective actions including adding diet texture information to nurse report sheets and staff training.
Deficiencies (1)
F 0805: The facility failed to ensure each resident received food prepared in a form designed to meet individual needs. A resident with a moist and minced diet order was given inappropriate snacks, leading to choking and death.
Report Facts
Residents affected: 1
Date of incident: Nov 29, 2025
Date diet order changed: Nov 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse 1 | Involved in administering food to resident and responding to choking incident | |
| Nurse 2 | New nurse being trained by Nurse 1 during the incident | |
| Director of Nursing | DON | Implemented corrective actions including adding diet texture to nurse report sheets |
Inspection Report
Renewal
Capacity: 80
Deficiencies: 12
Date: Sep 10, 2024
Visit Reason
The inspection was an unannounced re-licensure visit for Maple Springs Of North Logan Assisted Living Facility with 80 beds.
Findings
The inspection identified 12 rule noncompliances including issues with employee training, medication administration delegation, housekeeping training, pet vaccination, and documentation deficiencies. Several policies and procedures were found incomplete or not properly implemented.
Deficiencies (12)
R432-270-9(8)(a)-(c) The facility did not have documentation of 16 hours of one-on-one training for their caregivers.
R432-270-9(14)(a-g) The licensee did not ensure all employees had a health inventory.
R432-270-9(15) One medtech was observed to not sanitize or wash their hands between medication passes.
R432-270-19(7)(a-f) All employees who administered medications did not have a delegation from the facility's licensed healthcare professional.
R432-270-28(6) The licensee did not ensure that one pet was current on vaccinations.
R432-270-23(5) Chemicals were observed in the memory care kitchen, in the cupboards under the food warmers.
R432-270-23(6)(a-e) The facility's housekeepers were not trained.
R432-35-4(3) DACS did not reflect the current status of all employees.
R432-270-11(8)(a)-(g) The facility's admission agreement did not include a notice that the department has the authority to examine residents records to determine compliance with licensing requirements.
R432-270-13(1) There were two resident assessments that were not completed and signed before admission.
R432-270-14(1) One resident's service plan was not completed within seven calendar days of admission.
R432-270-18(5) Scissors and knives were accessible in "The Cove".
Report Facts
Rule noncompliances: 12
Facility licensed capacity: 80
Inspection date: Sep 10, 2024
Inspection Report
Routine
Deficiencies: 12
Date: Nov 16, 2023
Visit Reason
Routine inspection of Maple Springs Senior Living to assess compliance with healthcare regulations and standards.
Findings
The inspection identified multiple deficiencies including failure to notify physicians of significant resident changes, inadequate reporting of abuse and elopement, incomplete transfer documentation, pressure ulcer care deficiencies, inadequate supervision to prevent resident elopement, medication errors, incomplete laboratory testing and reporting, food safety violations, and incomplete medical record documentation.
Deficiencies (12)
F 0580: The facility failed to notify the physician of a resident's significant change in mental status, including suicidal ideation and threatening behavior with a knife.
F 0609: The facility did not report a resident's elopement to the State Survey Agency within required timeframes.
F 0622: The facility failed to provide adequate transfer documentation including contact information, discharge summaries, and special instructions for residents transferred to hospitals.
F 0686: The facility did not provide appropriate pressure ulcer care; a resident developed a new pressure ulcer and interventions to prevent its development were inadequate.
F 0689: The facility failed to provide adequate supervision to prevent a cognitively impaired resident from eloping despite known exit-seeking behaviors.
F 0757: The facility administered an ergocalciferol medication daily instead of weekly due to transcription error.
F 0758: A resident was prescribed an antipsychotic medication (Seroquel) for insomnia without a documented mental health diagnosis.
F 0770: The facility failed to obtain ordered laboratory tests; a complete blood count and a follow-up urinalysis were not completed or documented.
F 0775: The facility did not maintain complete laboratory records; a resident's urine culture results were missing from the medical record.
F 0812: Food in the kitchen refrigerator was not dated or labeled, and multiple areas in the kitchen were soiled with dust, debris, and black buildup.
F 0842: The facility's medical records were incomplete and inaccurately documented; a resident received Metoprolol Tartrate instead of the prescribed extended-release Metoprolol Succinate.
F 0881: The facility lacked an effective antibiotic stewardship program; a resident was treated with an antibiotic to which the infecting organism was resistant.
Report Facts
Sampled residents: 23
Ergocalciferol dose: 50000
Ergocalciferol dose frequency: 4
Pressure ulcer measurements: 2.5
Medication doses: 12.5
Medication doses: 50
Medication doses: 1
Medication doses: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Provided detailed information about resident 39's behaviors and elopement incident |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding facility policies, incidents, and medication errors |
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Described medication administration and lab result handling |
| Medical Doctor | Medical Doctor | Discussed urine culture results and antibiotic appropriateness |
| Dietary Manager | Dietary Manager | Discussed kitchen cleanliness and food storage practices |
Inspection Report
Routine
Deficiencies: 4
Date: Jan 13, 2022
Visit Reason
Routine inspection to assess compliance with regulatory requirements including physician visits, medical record maintenance, infection prevention and control, and COVID-19 testing protocols.
Findings
The facility failed to ensure timely physician visits for residents, maintain complete and accessible medical records, and implement an effective infection prevention and control program including proper PPE use and isolation procedures. Additionally, the facility did not conduct COVID-19 testing of unvaccinated staff according to community transmission guidelines.
Deficiencies (4)
F 0712: The facility did not ensure that 1 of 23 sampled residents was seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter.
F 0842: The facility did not ensure that medical records were complete, accurately documented, readily accessible, and systematically organized for 3 of 23 sampled residents; physician visit notes and hospice notes were missing from records.
F 0880: The facility failed to maintain an infection prevention and control program; unvaccinated new admissions on transmission-based precautions did not isolate properly, staff did not consistently use or sanitize PPE correctly, and meal trays were transported uncovered.
F 0886: The facility did not conduct COVID-19 testing of unvaccinated staff according to parameters set by the Secretary; routine testing two times per week was not consistently completed.
Report Facts
Residents sampled: 23
Residents affected by physician visit deficiency: 1
Residents affected by medical record deficiency: 3
Residents affected by infection control deficiency: 3
Unvaccinated staff sampled: 5
Facility PPE inventory: 1675
County COVID-19 positivity rate: 27.81
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding physician visit schedules, medical record issues, infection control practices, and COVID-19 testing | |
| Administrator (ADM) | Interviewed regarding outbreak status, infection control, PPE supply, and COVID-19 testing protocols | |
| Infection Preventionist (IP) | Interviewed regarding PPE use and infection control procedures | |
| Housekeeper (HK) 1 and 2 | Observed and interviewed regarding PPE use and cleaning practices | |
| Certified Occupational Therapist Assistant (COTA) | Observed and interviewed regarding PPE use during therapy | |
| Registered Nurse (RN) 1 and 2 | Interviewed regarding resident care and PPE use | |
| Certified Nursing Assistants (CNA) 2, 3, 5, 7, 8, 9 | Interviewed and observed regarding PPE use and resident care | |
| Housekeeping Manager (HKM) | Interviewed regarding PPE use and cleaning protocols |
Inspection Report
Routine
Deficiencies: 15
Date: Sep 26, 2019
Visit Reason
Routine inspection of Maple Springs Senior Living to assess compliance with regulatory requirements including resident care, medication management, infection control, and facility operations.
Findings
The facility was found to have multiple deficiencies including failure to treat residents with dignity during meal service, delayed physician notification for held medications, inadequate assistance with activities of daily living, delayed follow-up on lab results, medication errors including crushing extended-release medications, expired glucose control solutions, cross-contamination during meal service, and lack of antibiotic stewardship.
Deficiencies (15)
F 0550: Residents were not treated with dignity as some were served meals at different times and beverages in paper cups without clear justification.
F 0580: Resident 31's antihypertensive medications were held due to low blood pressure without timely physician notification as required by facility policy.
F 0676: Residents 2 and 19 did not receive appropriate assistance with eating, inconsistent with their care plans and documented needs.
F 0684: Multiple residents had delayed or inadequate follow-up on lab results and treatment orders, including resident 31's labs and resident 95's thrush treatment.
F 0712: Resident 22 was not seen by a physician at least once every 30 days for the first 90 days after admission as required.
F 0757: Resident 31's drug regimen was not free from unnecessary drugs; potassium wasting diuretic was given without potassium monitoring or supplementation, and blood pressure medication was held without physician notification.
F 0758: Residents 10 and 19 were prescribed psychotropic medications without documented indication, monitoring, or use of non-pharmacological interventions.
F 0759: Medication error rate exceeded 5% with errors including crushing extended-release and enteric-coated medications and incorrect dosing of biotin for resident 197.
F 0760: Resident 95 with thrush did not receive prescribed antifungal medication timely, with a delay of two days from symptom report to first dose.
F 0761: All glucose control solutions used for meter calibration were expired, risking inaccurate blood glucose readings.
F 0770: Resident 31 had an order for urine analysis with culture and sensitivity that was not completed as ordered.
F 0806: Residents 2 and 11 reported that food preferences and allergies were not consistently honored or updated; food service practices also included uncovered food and cross-contamination risks.
F 0880: Infection control lapses were observed including lack of hand sanitizer use between assisting residents during meals, risking cross-contamination.
F 0881: The facility did not implement an antibiotic stewardship program; prophylactic antibiotics were administered without medical rationale or appropriate monitoring.
F 0883: Resident 17 was not offered a second pneumococcal immunization (Prevnar 23) as recommended by CDC guidelines.
Report Facts
Medication error rate: 19.23
Residents affected by dignity deficiency: 7
Residents affected by medication monitoring deficiency: 1
Residents affected by ADL assistance deficiency: 2
Residents affected by lab follow-up deficiency: 6
Residents affected by psychotropic medication deficiency: 2
Residents affected by infection control deficiency: 2
Residents affected by antibiotic stewardship deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Crushed extended-release and enteric-coated medications for resident 27 and delayed medication documentation. |
| LPN 3 | Licensed Practical Nurse | Administered incorrect dose of Biotin to resident 197. |
| LPN 1 | Licensed Practical Nurse | Delayed administration of antifungal medication for resident 95. |
| CNA 6 | Certified Nursing Assistant | Did not sanitize hands between assisting residents during meals. |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding medication monitoring, infection control, and lab follow-up deficiencies. |
| Dietary Manager | Dietary Manager | Interviewed regarding food preferences, food service safety, and kitchen sanitation. |
| DA 1 | Dietary Aide | Observed using sanitizer buckets without sanitizer and cleaning kitchen surfaces improperly. |
| DA 2 | Dietary Aide | Observed filling sanitizer buckets and cleaning kitchen surfaces. |
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