Deficiencies (last 1 years)
Deficiencies (over 1 years)
20 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
153% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Routine
Capacity: 90
Deficiencies: 20
Date: Jan 28, 2024
Visit Reason
The inspection was an unannounced routine inspection of Haven at Sky Mountain Assisted Living Facility to review compliance with licensing and regulatory requirements.
Findings
The inspection identified multiple areas of noncompliance including incomplete resident assessments, missing hospice orders, lack of emergency evacuation plans for secure units, medication administration issues, incomplete staff training, unsecured hazardous materials, missing fire drill documentation, and deficiencies in resident rights notifications and management of resident funds.
Deficiencies (20)
The administrator has not completed a department-approved national certification program.
Significant change log was not maintained for 9 of 12 months; 1 resident's significant change was not documented.
One employee had not completed the required core competency training and orientation.
The administrator had not completed at least four hours of core competency training.
Health inventory was not completed for one employee.
Medication Technician not washing/sanitizing hands between resident contacts.
Not all medication technicians have been delegated by the current nurse.
One medication not available; no medication error incident report was filled out.
Medication errors are not being incorporated into the facility quality improvement process.
Narcotic logs containing PHI left unattended on medication carts.
Pet vaccination records have not been kept by the facility.
Memory care laundry unlocked detergent observed; air freshener on desk in memory care; laundry rooms and hair salon unsecured.
There was no documentation of the fire drills for the night shift for the 1st, 2nd, and 3rd quarters of 2024; documented drills did not include resident participants and their ability to evacuate.
The provider did not have an emergency evacuation plan on each secure unit that addresses the ability of the secure unit staff to evacuate the residents in case of emergency.
One resident did not have hospice orders and plan of care in his file.
7 residents did not have frequency documented on some ADLs; facility lacked written policy and procedure defining the level of nursing services.
The craft room in the basement was unlocked and had containers with scissors and pliers.
Does not manage resident funds as required by regulation.
Do not have emergency lighting, extra blankets, or emergency radio.
Do not have a current edition of a first aid manual.
Report Facts
Rule noncompliances: 134
Rule noncompliances: 25
Rule noncompliances: 44
Rule noncompliances: 22
Rule noncompliances: 3
Rule noncompliances: 206
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