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
Routine
Deficiencies: 13
Date: Dec 7, 2023
Visit Reason
Routine regulatory inspection of an assisted living facility to assess compliance with state licensing rules and regulations.
Findings
The inspection identified multiple deficiencies including incomplete resident assessments, missing emergency evacuation plans for hospice patients, lack of medication error reports, incomplete service plans, unlocked electrical panels, and deficiencies in emergency preparedness drills and documentation.
Deficiencies (13)
R432-270-10(9)(c) Two hospice patient residents did not have emergency evacuation plans.
R432-270-12(1) Four resident assessments were not complete.
R432-270-13(2) Three resident assessments were not used to develop their service plans.
R432-270-14(3)(b) One resident's service plan did not indicate who would be providing the services.
R432-270-18(2)(a)-(f) Eye drops, insulin pen and nasal spray were observed in resident room during medication pass. Other oral medications were administered by the medication technician.
R432-270-18(8) No medication error reports completed for 2 residents; medications not available in November 2023.
R432-270-18(9) Medication errors were not incorporated into the quality improvement process during the fourth quarter of 2022 and first and second quarters of 2023.
R432-270-20(1) No medication error reports provided prior to 10/27/2023; Assisted Living Director was not able to find them.
R432-270-22(5) Chemicals found in small kitchenette next to the reception. Removed by Wellness Director.
R432-270-24(1)(b) Electrical room next to room #302 was unlocked and accessed. Two electrical panels were observed to be open and accessed.
R432-270-25(8)(a)-(d) Fire and disaster drills did not include resident participants, problems encountered, and the ability of each resident to evacuate.
R432-270-25(11)(a)-(b) Emergency contact information was not prominently located throughout the facility.
R432-35-4(1) Four employee files did not include a signed criminal background screening authorization form that is available for review by the department.
Report Facts
Resident assessments incomplete: 4
Resident assessments not used for service plans: 3
Hospice patients without evacuation plans: 2
Employee files missing criminal background screening authorization: 4
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