Inspection Reports for
Welcome Home Assisted Living American Fork
1889 West 930 North, Pleasant Grove, UT, 84062
Back to Facility ProfileDeficiencies (over last year)
Deficiencies (over last year)
23 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
191% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Routine
Deficiencies: 23
Date: May 28, 2024
Visit Reason
Unannounced routine inspection to assess compliance with assisted living facility regulations.
Findings
The inspection identified multiple deficiencies including lack of documented corrective actions, missing training and certifications, unsecured narcotic books, unsecured oxygen tanks, fire door gaps, and missing emergency and disaster procedures.
Deficiencies (23)
The Administrator did not have a designee in writing to act as administrator when unavailable and did not document corrective actions on incident reports.
Two employees lacked ethics, reporting responsibility, confidentiality, fire and disaster plan, policy and procedure, 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.
The Administrator did not have 4 hours of dementia/Alzheimer training.
Two employees did not have tuberculosis tests on file.
Resident rights did not include a statement that residents may file complaints with the state long-term care ombudsman and advocacy groups concerning abuse, neglect, or misappropriation of property.
Facility admission agreements did not contain a provision for a 30-day notice before changes in established charges.
One hospice resident did not have an acceptable evacuation plan.
Three resident assessments were not accurate.
Nursing services policies were not developed or available.
Facility did not have a certified nurse aide on duty 24 hours a day.
No secure unit present at this location.
Narcotic books containing protected health information were left unsecured on top of medication carts.
Oxygen tanks in rooms 1 and 3 were not secured and fire doors had gaps greater than 1/4 inch.
There was no Silver Alert policy and no procedures for mass casualty, pandemic, death of resident, or interruption of public utilities.
Did not hold fire drills for previous 12 months, did not include resident participants or ability to evacuate; no disaster drills in previous 12 months.
Emergency information was not posted in prominent locations throughout the facility.
Two employee files did not have first aid or CPR certification; no current first aid manual available.
Policies for security and disposal of controlled substances and destruction of unused medications were not consistent with federal regulations.
Chemicals were found unsecured in the fire riser closet, hair salon, and above both medication carts.
Provider does not manage residents' funds.
Three employees were not entered into DACS, and the facility did not initiate certification; two employees were not linked to the facility in DACS.
Report Facts
Number of rule noncompliances: 25
Number of employees without documented 16 hr one-on-one training: 3
Number of employees without documented annual in-service training: 4
Number of employees without TB tests on file: 2
Number of employees without first aid/CPR certification: 2
Number of employees not in DACS: 3
Number of employees not linked to facility in DACS: 2
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