Inspection Reports for The Retreat at Sunriver
4480 S Arrowhead Canyon Dr, St. George, UT 84790, United States, UT, 84790
Back to Facility ProfileDeficiencies per Year
20
15
10
5
0
Unclassified
Inspection Report
Routine
Deficiencies: 20
Sep 24, 2024
Visit Reason
The inspection was an unannounced routine compliance check conducted by CCL licensors to ensure the facility's adherence to assisted living regulations.
Findings
The inspection identified 24 rule noncompliances across various areas including staffing, medication administration, resident rights, emergency preparedness, housekeeping, maintenance, and pet vaccination records. Several deficiencies were noted such as lack of designated administrator in absence, incomplete staff training, medication errors without proper reporting, and unsafe storage of hazardous materials.
Deficiencies (20)
| Description |
|---|
| Two residents sharing a room did not have a written request to share the room. |
| No designated administrator in writing to act when the administrator is unavailable. |
| One staff member did not have a current written job description. |
| Two staff members did not complete the required 16 hours of documented one-on-one training with a direct-care employee. |
| One staff member did not receive all required in-service training; one staff did not complete dementia and Alzheimer's specific training. |
| Medication technician did not wash/sanitize hands between resident contact. |
| Three residents received medications late; licensed health care professional was not notified and no medication error incident reports were completed. |
| Rights notification did not include statement about filing complaints with the state long-term care ombudsman and advocacy groups. |
| Two night shift staff were not certified nurse aides as required. |
| Two staff did not have 4 hours of documented one-on-one training in the secure unit. |
| Facility did not have an emergency evacuation plan addressing secure unit resident evacuation. |
| Substitution log for food service was not maintained. |
| Disinfectant spray was stored unlocked and accessible in employee breakroom. |
| One housekeeper did not have documented training on file. |
| Wheelchairs and garbage cans were blocking stairwell egress; five carbon dioxide canisters were not securely stored in the kitchen. |
| Emergency/disaster plan did not include mass casualty and explosion scenarios. |
| Resident ability to evacuate was not documented for all drills. |
| Facility did not have an emergency radio on-site. |
| One pet living at the facility did not have a vaccination record. |
| Resident charts were accessible in an unlocked RCC office. |
Report Facts
Rule noncompliances: 24
Residents with late medications: 3
Staff lacking required training: 4
Night shift staff uncertified: 2
Carbon dioxide canisters unsecured: 5
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