Deficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
37% better than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
The inspection was an unannounced routine inspection to review compliance with applicable rules for an Intermediate Care Facility for Individuals with Intellectual Disabilities.
Findings
The facility was found compliant with most rules, with no rule noncompliances noted during the inspection. The report details compliance with a wide range of regulatory requirements including client rights, staffing, medication management, emergency planning, and facility operations.
Report Facts
Number of rule noncompliances: 0
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jun 10, 2024
Visit Reason
A recertification survey was conducted from 6/10/2024 through 6/13/2024 to assess compliance with Conditions of Participation for Intermediate Care Facilities for Individuals with Intellectual Disabilities. During the survey, two complaints were investigated related to Client Protections, Active Treatment Services, and Health Care Services.
Complaint Details
Two complaints were investigated during the survey. The complaints were substantiated with deficiencies found in Active Treatment Services and Health Care Services, but not in Client Protections.
Findings
The facility was found to have no deficiencies in Client Protections but had substantiated deficiencies in Active Treatment Services and Health Care Services. Repeat deficiencies were cited from the previous survey, including issues with staff training, individual program plans, health care services, nursing services, drug storage and recordkeeping, and electrical equipment testing and maintenance.
Deficiencies (6)
W 189 Staff Training Program: The facility did not provide documented initial training for 2 of 4 sampled employees and infection control training for 4 of 4 sampled employees.
W 247 Individual Program Plan: The individual program plan did not include opportunities for client choice and self-management for 2 of 6 sampled supplemental clients.
W 318 Health Care Services: The facility failed to ensure specific health care service requirements were met, including protective and preventative health measures and infection control.
W 341 Nursing Services: The facility failed to provide appropriate protective and preventative health measures, including infection control and keeping drugs and biologics locked except when prepared for administration.
W 382 Drug Storage and Recordkeeping: The facility failed to keep all drugs and biologics locked except when being prepared for administration, and medication carts were found unlocked with broken locks.
K 921 Electrical Equipment - Testing and Maintenance: The facility failed to maintain documentation of inspections on patient-care related electrical equipment as required by NFPA 99, affecting 4 of 5 smoke compartments.
Report Facts
Sampled employees lacking training: 2
Sampled employees lacking infection control training: 4
Sampled supplemental clients lacking opportunities: 2
Clients involved in medication observation: 2
Smoke compartments affected: 4
Inspection Report
Renewal
Deficiencies: 9
Date: Jan 18, 2023
Visit Reason
A re-certification survey was conducted starting 01/17/2023 and completed on 01/18/2023 to assess compliance with Intermediate Care Facilities for Individuals with Intellectual Disabilities regulations as part of the facility's renewal process.
Findings
Multiple deficiencies were identified related to staff training, individual program plans, program implementation, management of inappropriate client behavior, nursing services, drug storage and recordkeeping, and space and equipment. The facility was found non-compliant in several areas requiring corrective action plans. No deficiencies were cited in the Life Safety Code survey.
Deficiencies (9)
W194 Staff training program was deficient as staff were unable to demonstrate skills and techniques necessary to implement individual program plans for clients.
W227 Individual program plans did not state specific objectives necessary to meet client needs as identified by comprehensive assessments.
W247 Individual program plans lacked opportunities for client choice and self-management for sampled clients.
W249 Program implementation was deficient as clients did not receive continuous active treatment programs with needed interventions and services in sufficient number and frequency.
W252 Program documentation was deficient as data relative to accomplishment of individual program plan objectives was not documented in measurable terms for sampled clients.
W289 Management of inappropriate client behavior was deficient as systematic interventions were not incorporated into individual program plans for sampled clients.
W341 Nursing services did not include appropriate protective and preventive health measures including infection control and instruction of personnel.
W382 Drug storage and recordkeeping were deficient as drugs and biologicals were not kept locked except when being prepared for administration.
W436 Space and equipment were deficient as the facility did not furnish and teach clients to use devices identified by the interdisciplinary team as needed.
Report Facts
Number of sampled clients: 8
Number of supplemental clients: 6
Number of clients referenced: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle McKissen | HPS III | Approved the Plan of Correction |
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