Deficiencies (over last year)
Deficiencies (over last year)
19 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
141% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Deficiencies: 19
Date: Dec 4, 2023
Visit Reason
This was an unannounced routine inspection of Cove Point Retirement assisted living facility to review compliance with licensing and regulatory requirements.
Findings
The inspection identified 19 rule noncompliances across various regulatory areas including licensing, administrator qualifications, personnel, resident rights, medication administration, and facility maintenance. Several deficiencies were noted with some requiring corrective action.
Deficiencies (19)
R432-270-5(3) The licensee did not ensure the facility is licensed as a type I facility when individuals under care are capable of exiting only with limited assistance of one person.
R432-270-8(1)(k)(a) The licensee did not maintain required staffing records for the preceding 12 months and did not review injury, accident, and incident reports as required.
R432-270-9(7)(a)(h) Four employees did not have documented orientation.
R432-270-11(9)(a)-(c) The licensee did not have an evacuation plan with a designated individual for hospice residents who were not able to evacuate without assistance.
R432-270-13(5) Three residents had significant changes that were not addressed with corrective action in the significant change log.
R432-270-15(6) At least one certified nurse aide was not on duty in a type II facility 24 hours a day.
R432-270-16(2)(a)-(b) The licensee did not ensure secure unit admission agreement was signed and did not ensure secure unit admission criteria were met.
R432-270-25(2)(a)-(d) Electrical panels in an unlocked hallway and elevator mechanical room were unlocked and accessible.
R432-270-25(5) Water temperature in accessible restroom was 131.2 degrees Fahrenheit, exceeding safe limits.
R432-270-23(5) Cleaning agents and bleaches were accessible in the unlocked storage room across from the elevator control room on the first floor.
R432-35-4(2)(b)-(h) Two employees did not submit fingerprints within 15 working days of their hire.
R432-270-19(14) The provider did not have documentation that RN was notified on medication errors for November 2023.
R432-270-19(15) The provider did not have medication error reports for 10 medications not available in November 2023.
R432-270-26(2)(a)-(c) When to notify the Silver Alert program was not included in the disaster plan.
R432-270-26(4)(a)-(k) The disaster plan did not include plans for missing resident, death of a resident, interruption of public utilities, explosion or bomb threat.
R432-270-26(6)(a)-(j) The disaster plan did not include instructions on how to recruit additional help after an emergency and delivery of essential care when personnel are reduced by emergency or alternate means.
R432-270-26(7)(a)-(d) The facility did not hold disaster drills in the previous year or during the current year and did not include ability of residents to evacuate.
R432-270-27(1)(a)-(b) Four employees worked together in varying pairs during overnight shift and did not have training in basic first aid or cardiopulmonary resuscitation.
R432-270-28(5) No birds were present in the facility.
Report Facts
Rule noncompliances: 19
Deficiencies cited: 135
Deficiencies cited: 47
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brian H April | Licensor | Conducted the inspection |
| Gordana Brian P | Licensor | Conducted the inspection |
| Evagelina Sissy Williams | Individual Informed of Inspection | Named in signature information on inspection checklist |
Loading inspection reports...
