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: Apr 9, 2024
Visit Reason
Unannounced routine inspection of Niitsuma Living Center to review compliance with assisted living facility regulations.
Findings
The inspection checklist shows multiple compliance and non-compliance findings across various regulatory requirements including licensing, personnel, resident rights, nursing services, medication administration, and safety. Some deficiencies were noted in service plans, medication management, and emergency preparedness.
Deficiencies (15)
R432-270-5(3) Licensing: The facility is licensed as a type I facility but was found non-compliant with requirements for type I licensing.
R432-270-7(3)(a-c) Administrator Qualifications: The administrator of type II small or limited-capacity assisted living facility did not meet the required qualifications.
R432-270-9(1)(l) Personnel: The licensee failed to ensure written job descriptions for positions including job title and qualifications.
R432-270-9(1)(l) Personnel: The licensee failed to ensure qualified staff perform services according to residents' service plans.
R432-270-9(1)(l) Personnel: The licensee failed to ensure personnel providing personal care are at least 18 years old and certified nurse aides have required training.
R432-270-9(1)(l) Personnel: The licensee failed to maintain written job descriptions for all positions.
R432-270-9(1)(l) Personnel: The licensee failed to ensure staff training and in-service requirements were met.
R432-270-14(3)(a)-(e) Service Plan: Resident service plans did not include frequency of services and changes in services.
R432-270-15(3)(a)-(c) Nursing Services: Medication delegation letters were not signed by a current registered nurse.
R432-270-15(6) Nursing Services: At least one certified nurse aide was not on duty 24 hours a day in type II facility.
R432-270-16(1) Secure Units: The facility does not have any secure units for residents with dementia or Alzheimer's disease.
R432-270-19(8) Medication Administration: A resident was assessed as unable to self-administer medication and no injections were administered.
R432-270-23(5) Housekeeping Services: Last fire inspection was on 2/10/2023; paint, disinfectant spray, lighter fuel, and hairspray were noted.
R432-270-28(8) Pets: The facility does not have written procedures for pet care and disposal of droppings.
R432-270-29(1) Respite Services: The facility does not provide respite services.
Report Facts
Number of rule noncompliances: 7
Number of deficiencies cited: 149
Number of corrected deficiencies during inspection: 7
Number of deficiencies not corrected: 45
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