In-service training

Use the related family guide: Staff training and coverage →

The licensee was out of compliance with R432-270-8(10)(b)(iv)(ix) by not ensuring each employee received documented in-service training that was relevant to their job responsibilities. During the inspection, the in-service trainings for 4 employees were requested and were not provided. This noncompliance was previously cited on 11/15/2023, 6/26/2025, 9/19/2025 and 11/6/2025.

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 March 3, 2026, the licensor verified that the administrator ensured that employees had received all required in-service training, as stated in rule.

Plans with emergency disaster authorities

Use the related family guide: Emergency planning →

The Licensee was out of compliance with R432-270-25(2)(b) by not ensuring that the emergency and disaster response plan included a plan that outlined arrangements for staff response and how they would provide additional staff to ensure the safety of any resident with physical or mental limitations. During the inspection, the emergency and disaster plan was reviewed and it did not outline arrangements for staff response or providing additional staff to ensure the safety of any resident with physical or mental limitations. This noncompliance was previously cited on 6/26/2025 and 9/19/2025.

Correction action: On December 22, 2025, the licensor verified that the Administrator ensured the emergency and disaster response plan outlined the protection or evacuation plan for each resident, including arrangements for staff response, or providing additional staff, to ensure the safety of any resident with a physical or mental limitation, as stated in rule.

Emergency and disaster response plan

The Licensee was out of compliance with R432-270-25(6)(g)(h)(i)(j) by not ensuring the emergency and disaster plans addressed the following: instructions on how to recruit additional help, supplies, and equipment to meet the residents' needs after an emergency or disaster; delivery of essential care and services to facility occupants by alternate means; delivery of essential care and services if additional persons were housed in the facility during an emergency; and delivery of essential care and services to facility occupants if personnel were reduced by an emergency. During the inspection, the licensee’s emergency and disaster plan was not updated to include the aforementioned components. This noncompliance was previously cited on 11/15/2023, 6/26/2025, and 9/19/2025.

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 December 22, 2025, the licensor verified that the Administrator ensured that the emergency and disaster response plan was complete, as stated in rule.

In-service training

Use the related family guide: Staff training and coverage →

The licensee was out of compliance with R432-270-8(10)(b)(iv)(vii)(ix) by not ensuring each employee received documented in-service training that was relevant to their job responsibilities. During the inspection, 4 employee files were reviewed and they did not receive all required annual In-services. This noncompliance was previously cited on 11/15/2023, 6/26/2025 and 9/19/2025.

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 March 3, 2026, the licensor verified that the administrator ensured that employees had received all required in-service training, as stated in rule.

Instruction & training for emergencies

Use the related family guide: Emergency planning →

The Licensee was out of compliance with R432-270-25(8)(b)(iii) 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 fire drills quarterly on each shift for staff and residents in accordance with Rule R710-3. During the inspection, the licensor requested the previous quarters fire drills, the drills provided were not simulated and did not include the residents ability to evacuate. This noncompliance was previously cited on 11/15/2023, 6/26/2025 and 9/19/2025.

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 December 11, 2025, the licensor verified that the fire and disaster drill instruction and training for emergencies was completed, as stated in rule.

Resident's legal rights

Use the related family guide: Resident rights →

The licensee was out of compliance with R432-270-9(2)(b) by not ensuring the administrator or designee gave each resident a written description of the resident's legal rights upon admission, including a statement that the resident could file a complaint with the state long-term care ombudsman and any other advocacy group concerning resident abuse, neglect, or misappropriation of resident property in the facility. During the inspection, 5 resident files did not contain a statement that the resident could file a complaint with the state long-term care ombudsman and any other advocacy group concerning resident abuse, neglect, or misappropriation of resident property in the facility. This noncompliance was previously cited on June 26, 2025.

Correction action: On November 6, 2025, the licensor verified that the Administrator had updated the resident's legal rights by including the statement that the resident could file a complaint with the state long-term care ombudsman and any other advocacy group concerning resident abuse, neglect, or misappropriation of resident property in the facility, as stated in rule.

Written admission, retention and transfer policies

Use the related family guide: Admission and resident assessment →

The Licensee was out of compliance with R432-270-10(1) by not ensuring that there were written admission, retention, and transfer policies that were available to the public upon request. During the inspection, the licensees admission, retention, and transfer policies were requested and none were provided. This non compliance was previously cited on November 15, 2023 and June 26, 2025.

Correction action: On November 6, 2025, the licensor verified that the licensee had written admission, retention, and transfer policies available upon request, as stated in rule.

Written resident agreement

Use the related family guide: Admission and resident assessment →

The licensee was out of compliance with R432-270-10(8)(c)(i)(vii) by not ensuring that the admission agreement specified the following: provision for a 30-day notice before any change in established charges; and a notice that the department had the authority to examine resident records to determine compliance with licensing requirements. During the inspection, 5 resident admission agreements did not include the provision for a 30-day notice before any change in established charges; and the admission agreements did not include a notice that the department had the authority to examine resident records to determine compliance with licensing requirements. This non-compliance was previously cited on November 15, 2023 and June 26, 2025.

Correction action: On November 6, 2025, the licensor verified that the admission agreements had been updated to include a provision for a 30-day notice before any change in established charges; and a notice that the department had the authority to examine resident records to determine compliance with licensing requirement, as stated in rule.

Resident assessment used for service plan

Use the related family guide: Records and service plans →

The Licensee was out of compliance with R432-270-13(2) by not ensuring that the resident assessment was used to develop, review and revise the service plan for each resident. During the inspection, 4 resident files were reviewed and their assessment was not used to develop their service plan. This noncompliance was previously cited on November 15, 2023 and June 26, 2025.

Correction action: On September 19, 2025, the licensor verified that the Administrator ensured that the resident assessments were used to develop the service plans, as stated in rule.

Written policies and procedures for level of nursing services

The Licensee was out of compliance with 432-270-14(1) by not ensuring that written policies and procedures were developed defining the level of nursing service provided by the facility. During the inspection, the policy and procedure binder was requested and their were no policy and procedures defining the level of nursing services. This noncompliance was previously cited on June 26, 2025.

Correction action: On November 6, 2025, the licensor verified that the Administrator had developed written policies and procedures for level of nursing services, as stated in rule.

Written incident and injury reports

Use the related family guide: Records and service plans →

The licensee was out of compliance with R432-270-20(6)(iv) by not ensuring written incident and injury reports were maintained to document resident deaths. During the inspection, the licensor did not observe an incident report to be filled out for 1 residents death.

Correction action: On September 19, 2025, the licensor verified that an incident report was completed upon a resident death, as stated in rule.

Person to direct housekeeping services

The Licensee was out of compliance with R432-270-22(2)(a-b) by not ensuring that designated housekeeping personnel posted routine laundry and cleaning schedules. During the inspection, there was no laundry or cleaning schedule posted for housekeepers. This noncompliance was previously cited on June 26, 2025.

Correction action: On November 6, 2025, the licensor verified that the Administrator ensured that laundry and housekeeping schedules were posted, as stated in rule.

Housekeeping personnel trained

The Licensee was out of compliance with R432-270-22(6)(a)-(e) by not ensuring that housekeeping personnel were trained regarding: preparing and using cleaning solutions; cleaning procedures; proper use of equipment; proper handling of clean and soiled linen; and procedures for disposal of waste. During the inspection, 4 employees who performed housekeeping duties were not trained in all required areas. This noncompliance was previously cited on June 26, 2025.

Correction action: On November 6, 2025, the licensor verified that the Administrator ensured that all employees who were responsible for housekeeping received the required training, as stated in rule.

Plans with emergency disaster authorities

Use the related family guide: Emergency planning →

The Licensee was out of compliance with R432-270-25(2)(b) by not ensuring that the emergency and disaster response plan included a plan that outlined arrangements for staff response and how they would provide additional staff to ensure the safety of any resident with physical or mental limitations. During the inspection, the emergency and disaster plan was reviewed and it did not outline arrangements for staff response or providing additional staff to ensure the safety of any resident with physical or mental limitations. This noncompliance was previously cited on June 26, 2025.

Correction action: On December 22, 2025, the licensor verified that the Administrator ensured the emergency and disaster response plan outlined the protection or evacuation plan for each resident, including arrangements for staff response, or providing additional staff, to ensure the safety of any resident with a physical or mental limitation, as stated in rule.

Emergency and disaster response plan

The Licensee was out of compliance with R432-270-25(6)(g)(h)(i)(j) by not ensuring the emergency and disaster plans addressed the following: instructions on how to recruit additional help, supplies, and equipment to meet the residents' needs after an emergency or disaster; delivery of essential care and services to facility occupants by alternate means; delivery of essential care and services if additional persons were housed in the facility during an emergency; and delivery of essential care and services to facility occupants if personnel were reduced by an emergency. During the inspection, the licensee’s emergency and disaster plan was not updated to include the aforementioned components. This non-compliance was previously cited on November 15, 2024 and June 26, 2025.

Correction action: On December 22, 2025, the licensor verified that the Administrator ensured that the emergency and disaster response plan was complete, as stated in rule.

Administrator duties

The Licensee was out of compliance with R432-270-7(1)(l) by not ensuring that the administrator reviewed at least quarterly every injury, accident, and incident to a resident or employee and documented the appropriate corrective action. During the inspection, the incident reports were not observed to have been reviewed by the Administrator quarterly. In addition, there was no corrective action documented on several of the incident reports. This non-compliance was previously cited on November 15, 2023 and June 26, 2025.

Correction action: On November 6, 2025, the licensor verified that incident reports were reviewed by the administrator and included an appropriate corrective action, as stated in rule.

Instruction & training for emergencies

Use the related family guide: Emergency planning →

The Licensee was out of compliance with R432-270-25(8)(b)(iii) 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 fire drills quarterly on each shift for staff and residents in accordance with Rule R710-3. During the inspection, the licensor requested the previous quarters fire drills. None were provided. This non-compliance was previously cited on November 15, 2024 and June 26, 2025.

Correction action: On December 11, 2025, the licensor verified that the fire and disaster drill instruction and training for emergencies was completed, as stated in rule.

Core competency training

Use the related family guide: Staff training and coverage →

The Licensee was out of compliance with R432-270-8(11) by not ensuring that the administrator completed a minimum of four hours of core competency training that included dementia and Alzheimer's specific training. During the inspection, the administrator did not have documentation that she had completed 4 hours of core competency training. This non-compliance was previously cited on November 15, 2023 and June 26, 2025.

Correction action: On November 6, 2025, the licensor verified that the administrator received annual core competency training that included 4 hours of Dementia and Alzheimer's specific training, as stated in rule.

In-service training

Use the related family guide: Staff training and coverage →

The Licensee was out of compliance with R432-270-8(10)(b)(i-xii) by not ensuring that every employee received documented in-service training, tailored to the employees job responsibilities. During the inspection, 4 employees were missing all areas of in-service training in the last year. This noncompliance was previously cited on November 15, 2023 and June 26, 2025.

Correction action: On March 3, 2026, the licensor verified that the administrator ensured that employees had received all required in-service training, as stated in rule.

Resident Assessment used for Service Plan

Use the related family guide: Records and service plans →

The Licensee was out of compliance with R432-270-14(2) by not ensuring that the resident assessment was used to develop, review and revise the service plan for each resident. During the inspection, 4 resident files were reviewed and their assessment was not used to develop their service plan.

Correction action: On November 6, 2025, the licensor verified that the assessments for 4 residents were used to develop their service plans, as stated in rule.

Written Resident Agreement

The Licensee was out of compliance with R432-270-11(8)(b)(f) by not ensuring that the admission agreement specified the following: provision for a 30-day notice before any change in established charges; and a notice that the department had the authority to examine resident records to determine compliance with licensing requirements. During the inspection, 5 resident admission agreements were reviewed and they did not include a provision for a 30-day notice before any change in established charges; and the admission agreements did not include a notice that the department had the authority to examine resident records to determine compliance with licensing requirements. This non-compliance was previously cited on November 15, 2023.

Correction action: On November 6, 2025, the licensor verified that the admission agreements had been updated to include a provision for a 30-day notice before any change in established charges; and a notice that the department had the authority to examine resident records to determine compliance with licensing requirement, as stated in rule.

Written admission, retention and transfer policies

Use the related family guide: Admission and resident assessment →

The Licensee was out of compliance with R432-270-11(1) by not ensuring that there were written admission, retention, and transfer policies that were available to the public upon request. During the inspection, the licensees admission, retention, and transfer policies were requested and none were provided. This non compliance was previously cited on November 15, 2023.

Correction action: On November 6, 2025, the licensor verified that the licensee had written admission, retention, and transfer policies available upon request, as stated in rule.

Core Competency Training

Use the related family guide: Staff training and coverage →

The Licensee was out of compliance with R432-9(10) by not ensuring that the administrator completed a minimum of four hours of core competency training that included dementia and Alzheimer's specific training. During the inspection, the administrator did not have the completed 4 hours of continuing education training. This non-compliance was previously cited on November 15, 2023.

Correction action: On November 6, 2025, the licensor verified that the administrator received a minimum of 4 hours of core competency training that included dementia and Alzheimer specific training, as stated in rule.

In-service Training

Use the related family guide: Staff training and coverage →

The Licensee was out of compliance with R432-270-9(9)(a-l) by not ensuring that every employee received documented in-service annual training tailored to the employees job responsibilities. During the inspection, 4 employees were missing all areas of in-service training in the last year. This non-compliance was previously cited November 15, 2023.

Correction action: On March 3, 2026, the licensor verified that the administrator ensured that employees had received all required in-service training, as stated in rule.

Administrator Duties

Use the related family guide: Administrator and safeguarding duties →

The Licensee was out of compliance with R432-270-8(1)(g) by not ensuring that the administrator reviewed at least quarterly every injury, accident, and incident to a resident or employee and documented the appropriate corrective action. During the inspection, the incident reports were reviewed and they were not observed to have been reviewed quarterly. In addition, there was no corrective action documented on the incident reports. This non-compliance was previously cited on November 15, 2023.

Correction action: On November 6, 2025, the licensor verified that incident reports were reviewed by the administrator and included an appropriate corrective action, as stated in rule.

Instruction & training for emergencies

Use the related family guide: Emergency planning →

The Licensee was out of compliance with R432-270-26(8)(b)(c) 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 and did not hold simulated fire drills quarterly on each shift for staff and residents in accordance with Rule R710-3. During the inspection, the Licensor reviewed the licensee's emergency and disaster plan. There were no simulated fire drills documented during the previous 12 months and only 1 documented disaster drill. This non-compliance was previously cited on November 15, 2024.

Correction action: On December 11, 2025, the licensor verified that the fire and disaster drill instruction and training for emergencies was completed, as stated in rule.

Emergency and Disaster Response Plan

Use the related family guide: Emergency planning →

The Licensee was out of compliance with R432-270-26(6)(g)(h)(i)(j) by not ensuring the emergency and disaster plans addressed the following: instructions on how to recruit additional help, supplies, and equipment to meet the residents' needs after an emergency or disaster; delivery of essential care and services to facility occupants by alternate means; delivery of essential care and services if additional persons were housed in the facility during an emergency; and delivery of essential care and services to facility occupants if personnel were reduced by an emergency. During the inspection, the licensee’s emergency and disaster plan was not observed to address the aforementioned components. This non-compliance was previously cited on November 15, 2024.

Correction action: On December 22, 2025, the licensor verified that the Administrator ensured that the emergency and disaster response plan was complete, as stated in rule.

Emergency Supplies

Use the related family guide: Emergency planning →

The Licensee was out of compliance with R432-270-26(10)(g) by not providing in-house equipment and supplies required in an emergency including a radio. During the inspection, the licensor observed the Licensee’s emergency and disaster supplies and there was no emergency radio observed. This non-compliance was previously cited on November 15, 2023.

Correction action: On September 19, 2025, the licensor verified that the Administrator ensured that an emergency radio was on-site at the facility, as stated in rule.

Material stored in locked area

Use the related family guide: Environment and maintenance →

The Licensee was out of compliance with R432-23(5) by not ensuring cleaning agents and bleaches were stored in a locked area to prevent unauthorized access. During the inspection, cleaning agents and bleaches were observed to be stored unlocked and accessible. This non-compliance was previously cited on November 15, 2023.

Correction action: On September 19, 2025, the licensor verified that all cleaning agents and chemicals were stored in a locked area to prevent unauthorized access, as stated in rule.

Wearing Identification Badge

Use the related family guide: Staff eligibility and identification →

The Licensee was out of compliance with R432-1-4(1)(a) by not ensuring that an employee providing direct care to a patient wore an identification badge. During the inspection, 1 direct care employee was not wearing an identification badge. This non-compliance was previously cited on November 15, 2023.

Correction action: On September 19, 2025, the licensor verified that all employees were wearing identification badges, as stated in rule.