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
Annual Inspection
Deficiencies: 13
Date: Jan 11, 2024
Visit Reason
A recertification survey was conducted from 01/08/2024 to 01/11/2024 to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with federal regulations, with deficiencies cited in resident self-administration of medications, comprehensive care planning, ADL care, tube feeding management, respiratory care, emergency preparedness, and life safety code compliance including fire drills and emergency lighting.
Deficiencies (13)
F554 - Resident Self-Administered Medications: The facility failed to ensure one resident was safe to self-administer inhaled medications as required by policy and physician orders.
F656 - Develop/Implement Comprehensive Care Plan: The facility failed to develop a care plan for one resident dependent on respiratory ventilators.
F677 - ADL Care Provided for Dependent Residents: The facility failed to provide adequate nail care for two residents dependent on staff for personal hygiene.
F693 - Tube Feeding Management/Restore Eating Skills: The facility failed to ensure appropriate treatment and documentation for residents receiving tube feeding.
F695 - Respiratory/Tracheostomy Care and Suctioning: The facility failed to obtain a physician order for supplemental oxygen for one resident and ensure proper respiratory care.
K223 - Doors with Self-Closing Devices: The facility failed to maintain fire/smoke doors so they shut to resist passage of fire/smoke as required.
K291 - Emergency Lighting: The facility failed to provide emergency lighting system testing and documentation for one month.
K321 - Hazardous Areas - Enclosures: The facility failed to maintain fire and smoke barriers in hazardous areas including dietary storage room door.
K355 - Portable Fire Extinguishers: The facility failed to maintain portable fire extinguishers and documentation of monthly tests.
K712 - Fire Drills: The facility failed to conduct required fire drills at unexpected times for all shifts quarterly.
K918 - Electrical Systems - Essential Electric System Maintenance and Testing: The facility failed to conduct weekly testing and documentation of the emergency generator.
K920 - Electrical Equipment - Power Cords and Extension Cords: The facility failed to ensure proper use of power strips and extension cords in patient care areas.
K921 - Electrical Equipment - Testing and Maintenance Requirements: The facility failed to maintain documentation of inspections for patient-care related electrical equipment.
Report Facts
Deficiencies cited: 12
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