Deficiencies (over last year)
Deficiencies (over last year)
32 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
305% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Routine
Deficiencies: 32
Date: Nov 5, 2024
Visit Reason
Unannounced routine inspection of Ridgeview Gardens Assisted Living Facility to assess compliance with state regulations and licensing requirements.
Findings
The inspection identified multiple areas of noncompliance including deficiencies in staff training, medication administration, emergency preparedness, resident rights documentation, maintenance, and record keeping. Several regulatory requirements were not met, such as lack of core competency training, incomplete incident reports, unsecured electrical panels, and absence of an emergency plan.
Deficiencies (32)
R432-270-6(2)(a-b) There were 2 QA meetings that the healthcare professional did not attend.
R432-270-9(7)(a-f) There was no core competency training approved by department.
R432-270-9(8)(a)-(c) There was 1 caregiver that did not have the documented 16 hours of one-on-one job training.
R432-270-9(9)(a)-(l) 6 employees did not have core competency in their file.
R432-270-9(10) The administrator did not have the completed four hours of dementia and Alzheimer's training.
R432-270-9(14)(a-g) There were 2 employees that were not skin-tested for tuberculosis within two weeks of hire.
R432-270-10(2)(a)-(b) The resident rights do not contain a statement that the resident may file a complaint with the state long-term care ombudsman and any other advocacy group concerning resident abuse, neglect, or misappropriation of resident property in the facility.
R432-270-13(1) One resident assessment was completed late.
R432-270-13(3)(a-b) 1 resident's status was not accurate at the time of assessment.
R432-270-14(2) The assessment is not used to develop the service plan for 3 residents.
R432-270-14(3)(a)-(e) Frequency of services provided is not stated for 7 residents.
R432-270-15(1) Did not ensure written policies and procedures were developed defining the level of nursing services provided by the facility.
R432-270-15(6) There was not a certified nurses aide on duty 24 hours a day.
R432-270-19(14) 4 medication errors where the RN was not notified.
R432-270-19(19)(a)-(b) Did not ensure policies governing the following are developed and implemented: security and disposal of controlled substances by the licensee or facility staff that are consistent with the Code of Federal Regulations, Title 21, Chapter II, Part 1307; and destruction and disposal of unused, outdated, or recalled medications.
R432-270-21(3)(a)-(j) 2 former employees files did not have few parts of the required documents after their termination.
R432-270-21(6) 8 residents deaths were not documented through written incident reports.
R432-270-25(1) Electrical panels in the service entrance were unsecured and accessible.
R432-270-26(2)(a)-(c) The facility did not coordinate plans with the state and local emergency disaster authorities to respond to potential emergencies and disasters.
R432-270-26(3) The facility did not have their emergency and disaster response plan in writing.
R432-270-26(4)(a)-(k) There was missing disaster for the following: severe weather, interruption of public utilities, explosions, bomb threats, and windstorms.
R432-270-26(5) The facility did not have an emergency plan for the department to review.
R432-270-26(6)(a)-(j) There was no emergency and disaster response plan that included how to recruit additional help, supplies, and equipment to meet the residents needs.
R432-270-26(8)(a)-(d) Do not have fire drills for night shift 1st, 2nd, 3rd of 2024 and 4th quarter of 2023; morning shift 2nd, 3rd quarters of 2024 and 4th quarter of 2023; Afternoon shift 2nd and 3rd quarters of 2024. Drills do not include resident participants or their ability to evacuate.
R432-270-26(9) Do not have fire drills for night shift 1st, 2nd, 3rd of 2024 and 4th quarter of 2023; morning shift 2nd, 3rd quarters of 2024 and 4th quarter of 2023; Afternoon shift 2nd and 3rd quarters of 2024. Drills do not include resident participants or their ability to evacuate.
R432-270-27(1)(a)-(d) First Aid Manual Expires end of 2024.
R432-270-27(1)(a)-(d) Do not have an emergency radio.
R432-270-28(4) Does not have small pets such as birds and hamsters.
R432-270-28(8) Does not have birds.
R432-270-29(1)-(9) Facility does not provide Respite Services.
R432-270-30(1)-(12) Facility does not provide Adult Day Care Services.
R432-35-4(3) There were 2 employees who were not connected to DACS within five working days.
Report Facts
Number of rule noncompliances: 26
Medication errors not reported: 4
Resident deaths not documented: 8
Employees missing core competency training: 6
Caregivers missing one-on-one job training: 1
Employees missing tuberculosis skin test: 2
Employees not connected to DACS: 2
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