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 this rule by not ensuring that medications were administered according to the prescribing order. During the inspection, one (1) resident did not have medications administered as prescribed. This non-compliance was previously cited on 4/29/2024, 6/26/2024, 9/17/2024, 10/29/2024 and 12/11/2024.

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 1/21/2025, the licensor verified that the medication technician administered mediation according to the prescribing order, 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 this rule by not ensuring that medications were administered according to the prescribing order. During the inspection,3 residents did not have medications administered as prescribed. This non-compliance was previously cited on 4/29/2024, 6/26/2024, 9/17/2024 and 10/29/2024.

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 1/21/2025, the licensor verified that the medication technician administered mediation according to the prescribing order, as stated in rule.

Notification of medication errors

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

The provider was out of compliance with this rule by not ensuring that the licensed healthcare professional was notified when medication errors occurred. During the inspection, 3 medication errors occurred and did not contain documentation that the licensed health care professional had been notified. This non-compliance was previously cited on 6/26/2024, 9/27/2024.and 10/29/2024.

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 12/26/2024, the licensor verified that the licensed health care professional was notified when a medication error occurred, as stated in rule.

Secure Unit Admission Agreement

Use the related family guide: Admission and resident assessment →

The provider was out of compliance with this rule by not having a secure unit admission agreement that indicated placement in a secure unit. During the inspection, 3 residents did not have the required secure unit agreements available for review. <br/><br/>This noncompliance was previously cited on 04/29/2024, 06/26/2024, 07/31/2024 and 9/17/2024.

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 12/11/2024, the licensor verified with the regional nurse, that each resident admitted to a secure unit had an admission agreement that indicated placement in the secure unit, as stated in rule.

Notification of medication errors

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

The provider was out of compliance with this rule by not ensuring that the licensed healthcare professional was notified when medication errors occurred. During the inspection, 2 medication errors occurred and did not contain documentation that the licensed health care professional had been notified.<br/><br/>This non-compliance was previously cited on 6/26/2024 and 9/27/2024.

Correction action: On 12/26/2024, the licensor verified that the licensed health care professional was notified when a medication error occurred, 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 this rule by not ensuring that medications were administered according to the prescribing order. During the inspection, 4 residents did not have medications administered as prescribed.<br/><br/><br/>This non-compliance was previously cited on 4/29/2024, 6/26/2024 and 9/17/2024.

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 1/21/2025, the licensor verified that the medication technician administered mediation according to the prescribing order, as stated in rule.

Provider shall protect each client

Use the related family guide: Administrator and safeguarding duties →

The provider was out of compliance with this rule by not protecting each resident from neglect. During the inspection, 1 resident was determined to have been neglected.

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 12/11/2024, the licensor verified with the regional nurse, that residents were protected from neglect, 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 maintaining staffing records for the preceding 12 months and by not completing an investigation when there was reason to believe a resident had been subjected to neglect. During the inspection, the facility's employee schedule for the previous 60 days was requested and could not be provided. A neglect investigation for a resident was requested and could not be provided.<br/><br/>This non-compliance was previously cited on 12/5/2023, 4/29/2024 and 6/26/2024.

Civil money penalty amount shown by Utah: $1,600.00. 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 12/11/2024, the licensor verified with the regional nurse, that an investigation was completed when there was reason to believe a resident had been subjected to neglect, as stated in rule.

Written incident and injury reports

Use the related family guide: Records and service plans →

The provider was out of compliance with this rule by not ensuring written incident reports were maintained to document resident neglect or other circumstances affecting the safety or well-being of residents. During the inspection, 2 incidents that required an incident report did not have written incident reports completed.<br/><br/>This non-compliance was previously cited on 12/5/2023, 6/6/2024 and 7/31/2024.

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 12/11/2024, the licensor verified with the regional nurse, that written incident and injury reports were maintained for all situations or circumstances, affecting the health, safety, or well-being of residents, as stated in rule.

One direct care staff in secure unit

Use the related family guide: Staff training and coverage →

The provider was out of compliance with this rule by not ensuring at least one direct-care staff was in the secure unit continuously. During the inspection, it was determined that the secure unit was not continuously staffed with direct-care staff.

Correction action: On 12/11/2024, the licensor verified with the regional nurse, that there was at least one direct-care staff in the secure unit continuously, 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 equipment were in operable condition and in compliance with Rule R432-6. During the inspection, the northeast fire doors would not latch when necessary. <br/><br/>This noncompliance was previously cited on 10/25/2023, 12/26/2023, 04/29/2024, 06/26/2024, and 07/31/2024.

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 10/29/2024, the licensor verified with the Regional Nurse that the Northeast fire door closed properly and was operational, as required by 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 equipment are in operable condition and in compliance with Rule R432-6. During the inspection, the northeast fire doors would not latch and during the fire drill conducted 07/22/2024 the fire doors would not automatically close when necessary. <br/><br/>This noncompliance was previously cited on 10/25/2023, 12/26/2023, 04/29/2024, and 06/26/2024.

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 10/29/2024, the licensor verified with the Regional Nurse that the Northeast fire door closed properly and was operational, as required by rule.

Control of odors

Use the related family guide: Environment and maintenance →

The provider was out of compliance with this rule by not ensuring control of odors by maintaining cleanliness. During the inspection, the southeast hallway had a strong urine smell. <br/><br/>This noncompliance was previously cited on 12/05/2023, 04/29/2024, and 06/26/2024.

Correction action: On 09/17/2024, the licensor verified that odors are controlled at stated by rule.

Written incident and injury reports

Use the related family guide: Records and service plans →

The provider was out of compliance with this rule by not ensuring that written incident reports and injury reports are maintained to document injuries. During the inspection, 1 resident received an injury and no written injury or incident report was completed related to that injury. <br/><br/>This noncompliance was previously cited on 12/05/2023 and 04/29/2024.

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 12/11/2024, the licensor verified with the regional nurse, that written incident and injury reports were maintained for all situations or circumstances, affecting the health, safety, or well-being of residents, as stated in rule.

Accurate and complete records

Use the related family guide: Records and service plans →

The provider was out of compliance with this rule by not ensuring accurate and complete records were maintained and easily accessible to staff and the department. During the inspection, two (2) employee files and 1 resident file were requested and were unable to be provided. This noncompliance was previously cited on 12/5/2023 and 4/29/2024.

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 07/31/2024, the licensor verified that accurate and complete records are maintained, as stated by rule.

Resident Assessment must reflect resident status and be signed

Use the related family guide: Admission and resident assessment →

The provider was out of compliance with this rule by not ensuring resident assessments accurately reflected the resident status' at the time of the assessments. During the inspection, the licensor reviewed 1 resident assessment and observed that the assessment did not accurately reflect the residents' status at the time of assessment. This noncompliance was previously cited on 12/5/2023, 12/26/2023, 2/12/2024, 3/25/2024 and 4/29/2024.

Civil money penalty amount shown by Utah: $800.00. 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 07/31/2024, the licensor verified that resident assessments accurately reflects the residents status and signed by a licensed healthcare professional, as stated by rule.

Signed and dated resident assessment completed prior to admission

Use the related family guide: Admission and resident assessment →

The provider was out of compliance with this rule by not ensuring that a signed and dated resident assessment was completed before admission. During the inspection, 1 resident assessment was not completed before admission. This noncompliance was previously cited on 4/29/2024 and 12/5/2023.

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 07/31/2024, the licensor verified that there was a signed and dated resident assessment completed prior to admission, as stated by rule.

Type II Hospice Patients

Use the related family guide: Hospice provisions →

The provider was out of compliance with this rule by not ensuring the type II assisted living facility accepted and retained a resident, on hospice, who could not evacuate the facility without significant assistance, and developed an emergency plan to evacuate the hospice resident in the event of an emergency. During the inspection, one (1) hospice patient resident was identified as requiring significant assistance to evacuate and the facility had not developed an emergency evacuation plan. This noncompliance was previously cited on 4/29/2024.

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 07/31/2024, the licensor verified that an emergency plan to evacuate the hospice resident in the event of an emergency and an emergency plan into the resident's service plan, as stated by rule.

Control of odors

Use the related family guide: Environment and maintenance →

The provider was out of compliance with this rule by not ensuring that odors were controlled by maintaining cleanliness. During the inspection, an environmental tour of the facility was conducted and the south hallway of the facility was observed to have a strong offensive odor. This noncompliance was previously cited on 12/5/2023 and 4/29/2024.

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 07/31/2024, the licensor observed there was a weekly menu posted in a public area, as stated by 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 maintenance was conducted to ensure that the facility fixtures were safe, operable, in good repair, and in compliance with Rule R432-6. During the inspection, the fire doors in the north east hallway were observed to not close and latch securely. Additionally, the fire door was "propped" open by a doorstop and the magnet was not working. This noncompliance was previously cited on 10/25/2023, 12/26/2023 and 4/29/2024.

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 10/29/2024, the licensor verified with the Regional Nurse that the Northeast fire door closed properly and was operational, as required by rule.

Administrator Duties

Use the related family guide: Administrator and safeguarding duties →

The provider was out of compliance with this rule by not ensuring the administrator designated, in writing, a competent employee, 21 years of age or older, to act as administrator when the administrator was unavailable for immediate contact and did not complete and document an investigation when there was reason to believe a resident had been subjected to abuse, neglect, or exploitation. During the inspection, the administrator designee in writing was requested and was unable to be provided. Additionally, a request was made for the investigation for the one (1) resident that had been identified as being subjected to suspected abuse, from 4/29/2024 and no abuse investigation was provided. This noncompliance was previously cited on 12/5/2023 and 4/29/2024.

Civil money penalty amount shown by Utah: $800.00. 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 07/31/2024, the licensor verified the administrator duties and reviewed there was no recent abuse or neglect investigations, as stated by rule.

Administrator Duties

Use the related family guide: Administrator and safeguarding duties →

The provider was out of compliance with this rule by not ensuring the administrator designated, in writing, a competent employee, 21 years of age or older, to act as administrator when the administrator was unavailable for immediate contact and did not complete and document an investigation when there was reason to believe a resident had been subjected to abuse, neglect, or exploitation. During the inspection, the administrator designee in writing was requested and was unable to be provided. Additionally, one (1) resident had been identified as being subjected to suspected abuse and the administrator had not completed and documented an investigation regarding that suspected abuse. This noncompliance was previously cited on 12/5/2023.

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 07/31/2024, the licensor verified the administrator duties and reviewed there was no recent abuse or neglect investigations, as stated by rule.

Resident Assessment must reflect resident status and be signed

Use the related family guide: Admission and resident assessment →

The provider was out of compliance with this rule by not ensuring resident assessments accurately reflected the resident status' at the time of the assessments. During the inspection, the licensor reviewed 2 resident assessments and observed that the assessments did not accurately reflect the residents' status at the time of assessments. This noncompliance was previously cited on 12/5/2023, 12/26/2023, 2/12/2024 and 3/25/2024.

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 07/31/2024, the licensor verified that resident assessments accurately reflects the residents status and signed by a licensed healthcare professional, as stated by rule.

Type II Hospice Patients

Use the related family guide: Hospice provisions →

The provider was out of compliance with this rule by not ensuring the type II assisted living facility accepted and retained a resident, on hospice, who could not evacuate the facility without significant assistance, and developed an emergency plan to evacuate the hospice resident in the event of an emergency. During the inspection, one (1) hospice patient resident was identified as requiring significant assistance to evacuate and the facility had not developed an emergency evacuation 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 07/31/2024, the licensor verified that an emergency plan to evacuate the hospice resident in the event of an emergency and an emergency plan into the resident's service plan, as stated by 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 maintenance was conducted to ensure that fixtures were safe, operable, in good repair, and in compliance with Rule R432-6. During the inspection, the fire doors in the north east hallway were observed to not close and latch securely. This noncompliance was previously cited on 10/25/2023 and 12/26/2023.

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 10/29/2024, the licensor verified with the Regional Nurse that the Northeast fire door closed properly and was operational, as required by rule.

Resident Assessment must reflect resident status and be signed

Use the related family guide: Admission and resident assessment →

The provider was out of compliance with this rule by not ensuring the resident's assessment accurately reflected the resident at the time of assessment. During the inspection, two (2) resident assessments were reviewed and did not accurately reflect the resident's status at the time of assessment.

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 07/31/2024, the licensor verified that resident assessments accurately reflects the residents status and signed by a licensed healthcare professional, as stated by rule.

Resident Assessment must reflect resident status and be signed

Use the related family guide: Admission and resident assessment →

The provider was out of compliance with this rule by not ensuring that resident assessments were accurate at the time of assessment. During the inspection, 2 resident assessments were reviewed and were not accurate at the time of assessment.

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 07/31/2024, the licensor verified that resident assessments accurately reflects the residents status and signed by a licensed healthcare professional, as stated by rule.

Written Resident Agreement

The provider was out of compliance with this rule by not ensuring that the resident signed a written admission agreement before admission. During the inspection, a signed resident admission agreement for 1 resident was requested and not provided.

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 2/12/2024, the licensor verified via a text message to the former administrator, that the resident refused to sign an admission agreement. The facility has taken every possible avenue to get the resident to sign an admission agreement and is in process of finding new placement for the resident, as stated by rule.

Type II accept and retain residents

Use the related family guide: Admission and resident assessment →

The provider was out of compliance with this rule by not ensuring the Type II licensee accepted and retained residents who were capable of evacuating the facility with the limited assistance of one person. During the inspection, 1 resident was observed to require more than the limited assistance of 1 person to transfer and evacuate the facility.

Civil money penalty amount shown by Utah: $500.00. 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 2/12/2024, the licensor verified that the facility had found new placement for the resident who did not meet criteria, as stated by rule. The resident was refusing to move out of facility and the facility was doing everything they could to find appropriate placement.

Residents Rights

Use the related family guide: Resident rights →

The provider was out of compliance with this rule by not ensuring that each resident was treated with respect, consideration, fairness, and full recognition of personal dignity and individuality. During the inspection, a resident, who required the use of a wheelchair, was identified as being previously admitted to the facility, when the facility did not have a wheelchair accessible room.

Civil money penalty amount shown by Utah: $500.00. 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 2/12/2024, the licensor verified that the facility offered the resident a wheelchair accessible room, as stated by rule. The resident refused to move to a wheelchair accessible room and was refusing to move out of the facility.

Resident Assessment must reflect resident status and be signed

Use the related family guide: Admission and resident assessment →

The provider was out of compliance with this rule by not ensuring that 2 resident assessments accurately reflected the resident's status at the time of assessment. During the inspection, 2 resident assessments did not accurately reflect the resident's status at the time of assessments.

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 07/31/2024, the licensor verified that resident assessments accurately reflects the residents status and signed by a licensed healthcare professional, as stated by rule.

Administrator Duties

Use the related family guide: Administrator and safeguarding duties →

The provider was out of compliance with this rule by not ensuring the Administrator admitted and retained only those residents who met admission criteria and whose needs could be met by the facility and did not review at least quarterly every injury, accident, and incident to a resident or employee and did not document appropriate corrective action. During the inspection, a resident was identified to not meet admission criteria and whose needs could not be met by the facility. Additionally, a review of incident reports from January 2023 to current was conducted. Corrective action was not observed to be documented on the reviewed incident reports.

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 12/26/2023, the Licensor verified that the provider understood the rule and the provider did not have any new admissions.

Type II accept and retain residents

Use the related family guide: Admission and resident assessment →

The provider was out of compliance with this rule by not ensuring the Type II licensee accepted and retained residents who were capable of evacuating the facility with the limited assistance of one person. During the inspection, 2 residents were observed to require more than the limited assistance of 1 person to transfer and evacuate the facility.

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 2/12/2024, the licensor verified that the provider had found new placement for the resident who did not meet criteria, as stated by rule. The resident refused to move out of the facility.

Residents Rights

Use the related family guide: Resident rights →

The provider was out of compliance with this rule by not ensuring that each resident was treated with respect, consideration, fairness, and full recognition of personal dignity and individuality. During the inspection, a resident, who required the use of a wheelchair, was identified as being previously admitted to the facility, when the facility did not have a wheelchair accessible room.

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 2/12/2024, the licensor verified that the facility offered the resident a wheelchair accessible room, as stated by rule. The resident refused to move to a wheelchair accessible room and was refusing to move out of the facility.