Deficiencies (over last year)
Deficiencies (over last year)
20 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
153% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Renewal
Capacity: 39
Deficiencies: 20
Date: Jan 25, 2025
Visit Reason
The inspection was conducted as a re-licensure renewal visit for the assisted living facility to ensure compliance with licensing requirements and regulations.
Findings
The inspection checklist reviewed multiple regulatory areas including licensing, administrator qualifications, personnel, resident rights, service plans, nursing services, medication administration, housekeeping, emergency preparedness, and more. Several noncompliance issues were identified across various rules, but no critical deficiencies or enforcement actions were noted.
Deficiencies (20)
R432-270-8(1)(a-p) The administrator failed to maintain a written and signed job description and did not meet all responsibilities including ensuring compliance with health and safety regulations.
R432-270-9(1)(a-e) The licensee did not ensure that qualified direct-care personnel were employed as required to meet residents' needs.
R432-270-9(7)(a-f) The licensee failed to ensure each employee received orientation and competency training including abuse and neglect reporting.
R432-270-9(12)(a-c) The licensee did not ensure employees were informed of legal obligations regarding resident rights and abuse reporting.
R432-270-10(2)(a-d) The licensee failed to protect residents' rights including admission, discharge, and grievance procedures.
R432-270-11(9)(a-c) The licensee did not ensure hospice services were provided as required for residents needing end-of-life care.
R432-270-13(1)(a-g) The licensee failed to ensure resident assessments and six-month reassessments were completed and documented timely.
R432-270-14(1)(a-e) The licensee did not ensure service plans were developed, reviewed, and updated for each resident.
R432-270-15(1)(a-f) The licensee failed to ensure nursing services were provided according to residents' needs and regulatory requirements.
R432-270-19(1)(a-n) The licensee did not ensure medication administration was properly documented and monitored, including self-administration and medication errors.
R432-270-21(1)(a-j) The licensee failed to maintain accurate and complete resident records including medication and incident documentation.
R432-270-22(1)(a-k) The licensee did not ensure food service sanitation and safety standards were met.
R432-270-23(1)(a-h) The licensee failed to maintain housekeeping and sanitation standards including pest control and cleanliness.
R432-270-25(1)(a-k) The licensee did not ensure maintenance services were provided to maintain a safe and functional environment.
R432-270-26(1)(a-k) The licensee failed to implement an adequate emergency and disaster preparedness plan.
R432-270-27(1)(a-k) The licensee did not ensure first aid supplies and emergency equipment were maintained and accessible.
R432-270-28(1)(a-k) The licensee failed to maintain safe and sanitary conditions for pets and ensure no pets posed a risk to residents.
R432-270-29(1)(a-i) The licensee did not ensure respite services were provided according to regulations.
R432-270-30(1)(a-g) The licensee failed to provide adult day care services as required.
R432-270-34(1)(a-k) The licensee did not ensure covered services were provided by qualified personnel and according to regulations.
Report Facts
Total licensed capacity: 39
Number of rule noncompliances: 139
Number of rule compliances: 53
Number of rules not assessed: 11
Number of corrected during inspection: 2
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