Material stored in locked area

Use the related family guide: Environment and maintenance →

The provider was out of compliance with R432-270-23(5) by not ensuring cleaning agents and poisonous and dangerous materials were stored in a locked area to prevent unauthorized access. During the inspection, the licensor observed that a container with bleach wipes and a disinfectant spray was accessible to the residents of the memory care unit. This is a repeat non-compliance from the inspections dated September 3, 2024, November 20, 2024, and April 23, 2025.

Correction action: The licensor verified that the unsecured chemicals had been removed and that the locking mechanism on the cupboard had been repaired.

Written schedule for maintenance

Use the related family guide: Environment and maintenance →

The provider was out of compliance with R432-270-25(1) by not ensuring that maintenance was conducted to ensure that the facility spaces were safe, operable, in good repair, and in compliance with R432-6. During the inspection, the licensor observed that multiple fire doors throughout the facility did not close and latch securely upon being tested. This is a repeat non-compliance from the inspection dated September 3, 2024 and April 23, 2025.

Correction action: On August 27, 2025, the licensor verified that the fire doors throughout the facility closed and latched securely, as required in rule.

Written schedule for maintenance

Use the related family guide: Environment and maintenance →

The provider was out of compliance with R432-270-25(1) by not ensuring all facility spaces were safe, in good repair, and in compliance with Rule R432-6. During the inspection, the licensor observed that 2 doors in the secure unit did not automatically close and latch securely without physical intervention upon being tested. Additionally, 1 resident was identified as having eloped from the secure unit by exiting one of the malfunctioning doors one month before the investigation.

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 August 27, 2025, the licensor verified that the fire doors throughout the facility closed and latched securely, as required in rule.

Material stored in locked area

Use the related family guide: Environment and maintenance →

The provider was out of compliance with R432-270-23(5) by not ensuring cleaning agents and poisonous and dangerous materials were stored in a locked area to prevent unauthorized access. During the inspection, the licensor observed that laundry detergent was accessible to the memory care residents. Additionally, other unsecured chemicals were observed to be accessible to non-memory care residents. <br/><br/>This is a repeat non-compliance from the inspections dated September 3, 2024 and November 20, 2024.

Correction action: On June 25, 2025, the licensor verified that the Administrator had removed the unsecured chemicals and that the locking mechanism in the memory care unit had been repaired to prevent unauthorized access, as stated in rule.

Resident Assessment used for Service Plan

Use the related family guide: Records and service plans →

The provider was out of compliance with R432-270-14(2) by not ensuring the resident assessment was used to develop, review, and revise the service plan for each resident. During the inspection, the licensor reviewed resident assessments and service plans and determined that they were not used to develop, review, and revise the service plans for 3 residents.<br/><br/>This is a repeat non-compliance for the inspection dated September 3, 2024.

Correction action: On June 25, 2025, the licensor verified, through a record review, that resident assessments were used to develop, review, and revise the service plan for each resident

Type II accept and retain residents

Use the related family guide: Admission and resident assessment →

The provider was out of compliance with R432-270-11(5)(a)(ii) by not ensuring the licensee accepted and retained residents who were capable of evacuating the facility with the limited assistance of one person. During the inspection, the Licensor identified 1 resident who required more than the limited assistance of one person to evacuate the facility.

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 June 25, 2025, the licensor verified that the facility did not accept and retain non-hospice residents who required more than the limited assistance of one person to evacuate the facility, as stated in rule.

Resident unable to self administer medications

Use the related family guide: Medication administration → · Compare the exact-label public finding cohort →

The provider was out of compliance with R432-270-19(7)(d) by not ensuring medications were administered according to the prescribing order. During the inspection, 1 resident was identified as not having received their medications due to the medication's unavailability. <br/><br/>This is a repeat non-compliance from the inspections dated September 3, 2024 and November 20, 2024.

Correction action: On June 25, 2025, the licensor verified that resident medications were administered according to physician orders, as stated in rule.

Written schedule for maintenance

Use the related family guide: Environment and maintenance →

The provider was out of compliance with R432-270-25(1) by not ensuring that maintenance was conducted to ensure that the facility spaces were safe, operable, in good repair, and in compliance with R432-6. During the inspection, the licensor observed that multiple fire doors throughout the facility did not close and latch securely upon being tested.<br/><br/>This is a repeat non-compliance from the inspection dated September 3, 2024.

Correction action: On June 25, 2025, the licensor verified that the two magnetic doors in the memory care unit closed without physical assistance. Both doors closed and locked as required in rule.

Type II Hospice Patients

Use the related family guide: Hospice provisions →

The provider was out of compliance with this rule by not ensuring that hospice services were part of the resident's service plan that explained who was responsible to meet the resident's needs. In addition, residents on hospice, who could not evacuate the facility without significant assistance in an emergency, did not have an evacuation plan developed. During the inspection, the licensor reviewed 2 hospice residents medical files that did not include a copy of the hospice orders for care, evacuation plans for resident who could not evacuate without significant assistance, and a service plan for a resident that did not incorporate hospice services into the plan.

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 11/20/2024, the licensor verified that hospice services were part of the resident's service plan that explained who was responsible to meet the resident's needs. In addition, residents on hospice, who could not evacuate the facility without significant assistance in an emergency, and had an evacuation plan developed, as stated in rule.

Update Status within 5 working days

Use the related family guide: Staff eligibility and identification →

The provider was out of compliance with this rule by not ensuring that each covered individual was connected to the facility in DACS within 5 working days of engagement. During the inspection, 3 employees current status was not reflected in DACS within 5 working days of engagement or termination.

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 2/7/2024, the licensor verified that the Administrator updated the current status of covered individuals in the Direct Access Clearance System within 5 working days of engagement or termination, as stated by rule.