Inspection Reports for The Ashford of Springville
333 South 950 West, Springville, UT, 84663
Back to Facility ProfileDeficiencies (last 1 years)
Deficiencies (over 1 years)
24 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
204% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Routine
Deficiencies: 24
Date: Sep 18, 2024
Visit Reason
The inspection was an unannounced routine regulatory compliance check of Ashford Assisted Living & Memory Care of Springville to review compliance with state licensing rules and regulations.
Findings
The inspection identified multiple rule noncompliances totaling 25, including deficiencies in resident assessments, service plans, medication administration, emergency preparedness, resident rights notifications, housekeeping, laundry services, and management of resident funds. Several staff training and documentation issues were also noted.
Deficiencies (24)
1 resident had a significant change and was not identified on the significant change log.
There were three staff who did not attend in-service trainings relevant to their job responsibilities.
1 staff did not have a tuberculosis skin-test within 14 days of hire.
No 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.
One person not able to evacuate with limited assistance of one person.
1 resident did not have hospice orders on file.
10 resident assessments were missing sections of the assessment and were not completed.
3 resident assessments were not completed prior to admission.
2 resident assessments did not accurately reflect the resident's status at the time of assessment.
1 resident had significant change and did not receive a significant change assessment.
10 resident service plans did not include the frequency of services for medication administration.
No Nursing services policies.
5 employees did not have a medication delegation from the delegating authority.
Narcotic logs containing PHI left out on medication cart 2nd floor.
1 resident on a therapeutic diet did not have a dietary consultation that was provided at least quarterly.
There were cleaning agents in the resident laundry room on the 1st floor.
There was one housekeeper who did not have required training.
The provider does not have a surety bond.
1 resident who had over $150, the funds are not deposited into an interest bearing account within 5 days of receipt.
Fire drills did not include the ability of each resident to evacuate.
The facilities emergency and disaster plan was not reviewed and updated as necessary to conform with local emergency plans.
The facility's emergency and disaster plan did not include instructions on how to recruit additional help, supplies, and equipment to meet the residents' needs after an emergency or disaster; delivery of essential care and services to facility occupants by alternate means; delivery of essential care and services if additional persons are housed in the facility during an emergency; and delivery of essential care and services to facility occupants if personnel are reduced by an emergency.
The facility did not have any emergency radio.
No notice that the department had the authority to examine resident records to determine compliance with licensing requirements.
Report Facts
Number of rule noncompliances: 25
Resident assessments not completed prior to admission: 3
Resident assessments missing sections: 10
Staff not attending in-service trainings: 3
Employees without medication delegation: 5
Residents on therapeutic diet without quarterly dietary consultation: 1
Residents with funds over $150 not deposited in interest bearing account within 5 days: 1
Rule citations: 146
Pages: 60
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