Inspection Reports for
Welcome Home Assisted Living
633 East Medical Drive, Bountiful, UT, 84010
Back to Facility ProfileDeficiencies (over last year)
Deficiencies (over last year)
27 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
242% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Routine
Deficiencies: 27
Date: Apr 3, 2024
Visit Reason
Unannounced routine inspection of Welcome Home Assisted Living Facility to assess compliance with state regulations and licensing requirements.
Findings
The inspection identified multiple areas of noncompliance including deficiencies in administrator duties, personnel training, resident assessments, service plans, medication administration, emergency preparedness, housekeeping, and record keeping. Several policies and procedures were unavailable for review as the administrator was offsite.
Deficiencies (27)
R432-270-6(1)(a-g) Policies and procedures were not available for review. Administrator was at a sister facility in American Fork.
R432-270-6(2)(a-b) Quality assurance committee did not consist of at least the administrator and a health care professional and did not meet quarterly.
R432-270-8(1)(a-p) Administrator was not reviewing and documenting corrective action for every injury, accident, and incident at least quarterly.
R432-270-9(7)(a)-(f) Licensee did not ensure 3 new hire employees received documented orientation and core competency training within 30 days of hire.
R432-270-9(9)(a)-(l) Licensee did not ensure each employee received documented annual in-service training on 3 employees.
R432-270-9(10) Facility administrator did not annually complete a minimum of four hours of core competency training including dementia and Alzheimer's specific training.
R432-270-11(2)(a)-(b) Resident assessments were not completed every six months as required.
R432-270-14(3)(a)-(e) Service plans did not include who would provide the services and how frequently the services would be provided.
R432-270-15(1) Policies and procedures defining nursing services were not available for review. Administrator was at a sister facility in American Fork.
R432-270-16(2)(a)-(b) Licensee did not ensure 3 residents admitted to the secure unit had admission agreements indicating placement in the secure unit.
R432-270-16(6) Licensee did not ensure qualified direct care personnel were on premises 24 hours a day.
R432-270-19(14) Licensee was unable to observe a medication pass.
R432-270-19(15) Licensee was unable to observe a medication pass.
R432-270-19(17)(a)-(b) Medication cart stored in dining room was unlocked and accessible.
R432-270-19(19)(a)-(b) Licensee did not have policies governing destruction and disposal of unused, outdated, or recalled medications.
R432-270-20(1) Facility does not manage any resident funds.
R432-270-21(1) Licensee did not have policy and procedures easily accessible to staff and the department.
R432-270-23(6)(a)-(e) Licensee did not ensure housekeeping personnel were trained in housekeeping duties.
R432-270-24(1)(a)-(c) Facility did not have at least one washer and one clothes dryer available for resident use.
R432-270-26(2)(a)-(c) Licensee did not develop and coordinate emergency plans with state and local authorities and lacked plans for mass casualty and interruption of public utilities.
R432-270-26(6)(a)-(j) Emergency and disaster response plan lacked key elements including names of persons in charge, notification priorities, and delivery of essential care under emergency conditions.
R432-270-26(8)(a)-(d) Fire and disaster drills were not held the required amount of times.
R432-270-26(10)(a)-(g) Licensee did not have potable water and a radio in-house for emergencies.
R432-270-26(11)(a)-(b) Names and numbers of emergency personnel were not posted in public locations throughout the building.
R432-270-28(6) Licensee did not ensure pets for 2 residents had current vaccinations.
R432-35-4(1) Provider did not enter required information into DACS before engagement as a covered individual.
R432-35-4(2)(a)-(b) Provider did not ensure 1 employee had a signed criminal background screening authorization form.
Report Facts
Number of rule noncompliances: 30
Date: Apr 3, 2024
Date: Apr 8, 2024
Date: Apr 10, 2024
Date: Apr 12, 2024
Date: Apr 19, 2024
Date: May 3, 2024
Date: Apr 4, 2024
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