Inspection Reports for Welcome Home Assisted Living American Fork
1889 West 930 North, Pleasant Grove, UT, 84062
Back to Facility ProfileDeficiencies (last 1 years)
Deficiencies (over 1 years)
20 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
153% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 20
Date: May 28, 2024
Visit Reason
The inspection was an unannounced routine regulatory compliance check of Welcome Home Assisted Living facility to review compliance with licensing rules and regulations.
Findings
The inspection identified 25 rule noncompliances including issues with administrator duties, staff training, resident rights, medication administration, maintenance, emergency preparedness, and record keeping. Several policies and procedures were missing or incomplete, and some safety hazards were noted.
Deficiencies (20)
The Administrator did not have a designee in writing to act as administrator when unavailable and did not document corrective actions on incident reports.
Facility admission agreements did not contain a provision for a 30 day notice before change in established charges.
Do not have an acceptable evacuation plan for 1 resident.
The facility did not have a CNA on duty 24 hours a day.
Narcotic books containing PHI were left unsecured on top of medication carts.
Oxygen tanks in rooms 1 and 3 were not secured. Fire doors had a gap greater than 1/4 inch.
Did not hold fire drills for previous 12 months, did not include resident participants and ability to evacuate. No disaster drills previous 12 months.
There was no Silver Alert policy or procedure for mass casualty, pandemic, death of resident, or interruption of public utilities.
Do not have nursing services policies.
Do not have policies for security and disposal of controlled substances consistent with federal regulations.
Two employees did not have ethics, residents' rights, confidentiality, fire and disaster plan, policy and procedure, reporting responsibility, and core competency training.
Three employees did not have documented 16 hours of one-on-one job training.
Four employees did not have documented annual in-service training relevant to their job responsibilities including dementia/Alzheimer's training.
Two employees did not have TB tests on file.
Facility did not have a current first aid manual.
Emergency information was not posted in prominent locations throughout the facility.
Two employee files did not have first aid/CPR training documentation.
Chemicals were found in the fire riser closet, hair salon, and above both medication carts.
Provider does not manage residents' funds.
Three employees were not in DACS, and the facility did not initiate certification. Two employees were not linked to the facility.
Report Facts
Number of rule noncompliances: 25
Census: 120
Total Capacity: 56
Deficiencies cited: 25
Employees not in DACS: 3
Employees not linked to facility: 2
Employees lacking 16 hr training: 3
Employees lacking ethics and core training: 2
Employees lacking annual in-service training: 4
Employees lacking TB tests: 2
Rule noncompliances related to medication: 6
Rule noncompliances related to emergency preparedness: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cameron Corry | Administrator | Named in relation to inspection and findings |
| Gordana S. | Licensor | Conducted the inspection |
| Brian H. | Licensor | Conducted the inspection |
| Troy K. | Licensor | Conducted the inspection |
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