Written policies and procedures for level of nursing services

The provider was out of compliance with this rule by not ensuring written policies and procedures were developed defining the level of nursing services provided by the facility. During the inspection, no policy that defined the level of nursing services provided by the facility was provided. This noncompliance was previously cited on 5/1/2024 and 7/16/2024.

Civil money penalty amount shown by Utah: $100.00. Utah describes a civil money penalty as a department fine; the amount alone is not a quality or safety score. Read Utah's guidance ↗

Correction action: On 10/8/2024, the Licensor verified that the provider had developed and implemented policies and procedures for level of nursing services. as stated in rule.

Written schedule for maintenance

Use the related family guide: Environment and maintenance →

The provider was out of compliance with this rule by not ensuring that facility spaces were safe, operable, in good repair and in compliance with Rule R432-6. During the inspection, an environmental tour of the secure unit was conducted. Multiple fire doors did not have astragal devices and a large gap between the doors, when shut, was observed. One fire door would not close due to getting caught on the other fire door. This noncompliance was previously cited on 5/1/2024 and 7/16/2024.

Civil money penalty amount shown by Utah: $100.00. Utah describes a civil money penalty as a department fine; the amount alone is not a quality or safety score. Read Utah's guidance ↗

Correction action: On 10/8/2024, the Licensor verified that the fire doors were functioning as designed, as stated in rule.

Instruction & training for emergencies

Use the related family guide: Emergency planning →

The provider was out of compliance with this rule by not providing personnel and residents with instruction and training in accordance with the plans to respond appropriately in an emergency. The licensee did not: hold simulated disaster drills semi-annually in accordance with Rule R710-3; and document participants, problems encountered, and the ability of resident to evacuate. During the inspection, no disaster drills were provided, the fire drill provided did not include resident participants or their ability to evacuate. This noncompliance was previously cited on 5/1/2024 and 7/16/2024.

Civil money penalty amount shown by Utah: $100.00. Utah describes a civil money penalty as a department fine; the amount alone is not a quality or safety score. Read Utah's guidance ↗

Correction action: on 10/8/2024, the Licensor verified that the provider had completed fire drills, to include participants and residents ability to evacuate, as stated in rule.

Emergency Evacuation Plan

Use the related family guide: Emergency planning →

The provider was out of compliance with this rule by not providing an emergency evacuation plan on the secure unit that addressed the ability of the secure unit staff to evacuate the residents in case of emergency. During the inspection, the provider did not provide an emergency evacuation plan for the secure unit that addressed the ability of the secure unit staff to evacuate the residents in case of emergency. This noncompliance was previously cited on the 5/1/2024.and 7/16/2024 inspections.

Civil money penalty amount shown by Utah: $100.00. Utah describes a civil money penalty as a department fine; the amount alone is not a quality or safety score. Read Utah's guidance ↗

Correction action: On 10/8/2024, the Licensor verified that the provider developed and implemented an emergency evacuation plan for the secured unit, as stated in rule.

Administrator Duties

Use the related family guide: Administrator and safeguarding duties →

The provider was out of compliance with this rule by not completing an investigation when there was reason to believe a resident had been subjected to abuse, neglect, or exploitation and by not having the administrator designate, in writing, a competent employee, 21 years of age or older, to act as administrator when the administrator was unavailable for immediate contact. During the inspection, the licensor reviewed incident reports for the previous 90 days. Incident report's were identified that alleged abuse and were not investigated and the licensor requested the administrative designee letter and no letter was provided. This noncompliance was previously cited on 5/1/2024.

Civil money penalty amount shown by Utah: $400.00. Utah describes a civil money penalty as a department fine; the amount alone is not a quality or safety score. Read Utah's guidance ↗

Correction action: On 7/16/2024 the licensor verified that the abuse investigation was completed on site and that the administrator had an administrative designee in writing, as stated in rule.

Administrator Duties

Use the related family guide: Administrator and safeguarding duties →

The provider was out of compliance with this rule by not completing an investigation when there was reason to believe a resident had been subjected to abuse, neglect, or exploitation. During the inspection, the licensor reviewed incident reports for the previous 90 days. Incident report's were identified that alleged abuse and were not investigated.

Civil money penalty amount shown by Utah: $200.00. Utah describes a civil money penalty as a department fine; the amount alone is not a quality or safety score. Read Utah's guidance ↗

Correction action: On 7/16/2024 the licensor verified that the abuse investigation was completed on site and that the administrator had an administrative designee in writing, as stated in rule.