Inspection Reports for
The Retreat at Sunriver
4480 S Arrowhead Canyon Dr, St. George, UT 84790, United States, UT, 84790
Back to Facility ProfileDeficiencies (over last year)
Deficiencies (over last year)
21 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
166% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Routine
Deficiencies: 21
Date: Sep 24, 2024
Visit Reason
Unannounced routine inspection of The Retreat at Sunriver St. George assisted living facility to assess compliance with licensing and regulatory requirements.
Findings
The inspection identified 24 rule noncompliances including issues with administrator duties, personnel training, resident rights notifications, medication administration errors, emergency preparedness, housekeeping, and maintenance. Several deficiencies were noted with staff training, documentation, and safety protocols.
Deficiencies (21)
R432-270-5(6) Two residents sharing a room did not have a written request to share the room.
R432-270-8(1)(b) There was no designatee in writing to act as administrator when the administrator is unavailable.
R432-270-9(5) One staff member did not have a current written job description.
R432-270-9(8) Two staff did not have the completed 16 hours of documented one-on-one training with a direct-care employee.
R432-270-9(9) One staff did not receive all required in-service training including dementia and Alzheimer's specific training.
R432-270-9(11) Facility not inspecting until November 2025 for continuing professional education requirements.
R432-270-15(6) Two night shift staff were not certified nurse aides as required.
R432-270-16(3) Two staff did not have 4 hours of documented one-on-one training in the secure unit.
R432-270-16(5) Facility did not have an emergency evacuation plan addressing the ability of secure unit staff to evacuate residents.
R432-270-19(14) Three medications were given late and the licensed health care professional was not notified of medication errors.
R432-270-19(15) Medication error incident reports were not completed for late medication administration.
R432-270-20(1) The facility does not manage resident funds as required.
R432-270-21(2) Resident charts were accessible in an unlocked office.
R432-270-22(3)(d) A substitution log for meals served was not maintained.
R432-270-23(5) Disinfectant spray was stored unlocked and accessible in employee breakroom.
R432-270-23(6)(b) One housekeeper did not have documented training on file.
R432-270-25(1) Wheelchairs and garbage cans were blocking stairwell egress. Carbon dioxide canisters were not securely stored in the kitchen.
R432-270-26(4) Emergency/disaster plan did not include mass casualty and explosion scenarios.
R432-270-26(8) Resident ability to evacuate was not documented for all drills.
R432-270-26(10)(g) Facility did not have an emergency radio on-site.
R432-270-28(6) One pet living at the facility did not have a vaccination record.
Report Facts
Rule noncompliances: 24
Residents sharing room without written request: 2
Staff without required training: 4
Medications given late: 3
Non-certified night shift staff: 2
Pet without vaccination record: 1
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