Resident unable to self administer medications

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The Licensee was out of compliance with R432-270-19(7)(d) by not ensuring medications were administered according to the prescribing order. During the inspection, a medication was not administered according to the prescribing order for 1 resident. This is a repeat noncompliance from the inspections dated August 13, 2024, October 28, 2024, and January 29, 2025.

Civil money penalty amount shown by Utah: $300.00. 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 April 28, 2025, the licensor verified that the Licensee ensured facility staff only administered medications after delegation by a licensed health care professional, as stated in rule. All unlicensed medication technicians were documented to have had medication delegation under the facility Nurse's license.

Resident unable to self administer medications

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The Licensee was out of compliance with R432-270-19(7)(b) by not ensuring facility staff administered medications only after delegation by a licensed health care professional under the scope of their practice. During the inspection, it was noted that 5 facility staff administered medications without delegation by the current licensed health care professional. This is a repeat noncompliance from the inspection dated January 29, 2025.

Civil money penalty amount shown by Utah: $300.00. 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 April 28, 2025, the licensor verified that the Licensee ensured medications were administered according to the prescribing order, as stated in rule.

Critical incidents reporting requirements

The provider was out of compliance with this rule by not ensuring that when a critical incident occurred, the facility submitted a report of the critical incident to the office in the format required by the office within one business day of the critical incident occurrence. During the inspection, 1 resident had an injury of unknown origin and a critical incident was not reported to the office within 1 business day. This is a repeat noncompliance from the inspection dated 10/28/2024.

Correction action: On April 28, 2025, the licensee verified that the facility submitted critical incident reports to the office in the format required by the office within one business day of the critical incident occurrence, as stated in rule.

Administrator Duties

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The provider was out of compliance with this rule by not ensuring the administrator completed an investigation when there was reason to believe a resident had been subject to abuse and reported any suspected abuse in accordance with Section 62A-3-305. During the inspection, it was noted that 1 resident had an injury of unknown origin that was not investigated and was not reported to Adult Protective Services or the local police. This is a repeat noncompliance from the inspections dated 3/27/2024 and 12/4/2024.

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 March 20, 2025, the licensor verified that the Licensee completed an investigation and reported allegations to Adult Protective Services or the police when an injury of unknown origin was identified, as stated in rule.

Resident unable to self administer medications

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The provider was out of compliance with this rule by not ensuring (b) facility staff administered medications only after delegation by a licensed health care professional under the scope of their practice and (d) ensured medications were administered according to the prescribing order. During the inspection, it was noted that 2 facility staff administered medications without delegation by the licensed health care professional and medications were not administered according to the prescribing order for 1 resident. This is a repeat noncompliance from the inspections dated 8/13/2024 and 10/28/2024.

Civil money penalty amount shown by Utah: $300.00. 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 April 28, 2025, the licensor verified that the Licensee ensured medications were administered according to the prescribing order, as stated in rule.

Provider shall protect clients from abuse, prevent abuse

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The provider was out of compliance with this rule by not ensuring residents were protected from harm, mistreatment, and any action that compromised the health and safety of residents through acts or omissions. During the inspection, it was noted that after discovering a large number of narcotic medications had been tampered with for multiple residents', the facility reported staff were drug tested as part of the correction plan; 6 staff were not drug tested per the correction plan. This is a repeat noncompliance from inspections dated 8/13/2024 and 10/28/2024.

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 March 20, 2025, the licensor verified that the Licensee drug tested all staff when there was a concern with missing narcotics and protected residents from harm, mistreatment, or any action that compromised the health and safety of the residents through acts or omissions, as stated in rule.

Administrator Duties

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The provider was out of compliance with this rule by not ensuring the administrator reported any suspected abuse in accordance with Section 62A-3-305. During the inspection, it was noted that one allegation of suspected abuse was not documented to have been reported to Adult Protective Services or the local police.

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 20, 2025, the licensor verified that the Licensee completed an investigation and reported allegations to Adult Protective Services or the police when an injury of unknown origin was identified, as stated in rule.

Provider shall protect clients from abuse, prevent abuse

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The provider was out of compliance with this rule by not ensuring residents were protected from neglect, mistreatment, and any action that compromised the health and safety of residents through acts or omissions. During the inspection, 1 resident was noted to have alleged neglectful behavior and mistreatment from a staff member; no actions were taken to protect the resident, and the staff member was allowed to continue providing care to the resident. Additionally, after discovering a large number of a resident's narcotic medications were missing, the facility reported staff were drug tested as part of the correction plan; 2 staff were not drug tested per the correction plan.

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 March 20, 2025, the licensor verified that the Licensee drug tested all staff when there was a concern with missing narcotics and protected residents from harm, mistreatment, or any action that compromised the health and safety of the residents through acts or omissions, 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 medications were administered according to the prescribing order. During the inspection, it was noted that medications were not administered according to the prescribing order for 1 resident.

Correction action: On April 28, 2025, the licensor verified that the Licensee ensured medications were administered according to the prescribing order, as stated in rule.

Provider shall protect clients from abuse, prevent abuse

Use the related family guide: Administrator and safeguarding duties →

The provider was out of compliance with this rule by not ensuring clients were protected from abuse, neglect, harm, and mistreatment and any action that may have compromised the health and safety of clients through acts or omissions and did not instruct and encourage others to do the same. During the inspection, 1 resident was identified as having an injury of unknown origin and the provider did not ensure the resident was protected from any action that may have compromised their health and safety. Additionally, 2 residents were identified as alleged victims of abuse and the provider did not protect them and did not instruct and encourage others to do the same.

Correction action: On March 20, 2025, the licensor verified that the Licensee drug tested all staff when there was a concern with missing narcotics and protected residents from harm, mistreatment, or any action that compromised the health and safety of the residents through acts or omissions, as stated in rule.

Accurate and complete records

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The provider was out of compliance with this rule by not ensuring accurate and complete records were maintained. The licensee did not safely file and store records and did not ensure they remained easily accessible to staff and the department. During the inspection, 1 incident report noted in the incident report log was not available for review.

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 4/22/2024, the licensor verified that the Administrator, was safely filing and storing records and that they remained easily accessible to staff and the department, as stated by rule.

Administrator Duties

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The provider was out of compliance with this rule by not ensuring the administrator completed an investigation when there was reason to believe a resident had been subjected to abuse or neglect. During the inspection, the licensor reviewed the administrator's investigation of an abuse allegation incident that had been reported to the Department. The investigation contained incongruous pieces of information that were not investigated that were relevant to the final determination of the abuse accusation. The licensor also observed on the incident report log, a resident was reported to have sustained an injury of unknown origin. The administrator stated the incident listed on the report log did not have an incident note attached to it and no investigation was completed.

Civil money penalty amount shown by Utah: $1,000.00. 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 4/22/2024, the licensor verified that the Administrator, completed an investigation when there was reason to believe a resident has been subject to abuse, neglect or exploitation, as stated by rule.