The Lodge at Jordan River.

[R432-270-19(7)(a)-(f)] 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.

[R432-270-19(7)(a)-(f)] 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. [R432-270-19(14)] 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.

[R432-270-16(2)(a)-(b)] 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. [R432-270-19(14)] 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. [R432-270-19(7)(a)-(f)] 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. [R380-80-4(1)] 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. [R432-270-8(1)(a)-(p)] 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. [R432-270-21(6)] 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. [R432-270-16(4)] 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.

[R432-270-25(1)] 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.

[R432-270-25(1)] 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. [R432-270-23(3)] 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. [R432-270-21(6)] 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.

[R432-270-21(1)] 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. [R432-270-13(3)(a)-(b)] 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. [R432-270-13(1)] 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. [R432-270-11(10)(a)-(c)] 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. [R432-270-23(3)] 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. [R432-270-25(1)] 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. [R432-270-8(1)(a)-(p)] 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.

[R432-270-8(1)(a)-(p)] 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. [R432-270-13(3)(a)-(b)] 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. [R432-270-11(10)(a)-(c)] 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. [R432-270-25(1)] 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.

[R432-270-13(3)(a)-(b)] 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.

[R432-270-13(3)(a)-(b)] 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.

[R432-270-11(8)(a)-(g)] 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. [R432-270-11(5)(a-c)] 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. [R432-270-10(5)(a)-(x)] 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. [R432-270-13(3)(a)-(b)] 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.

[R432-270-8(1)(a)-(p)] 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. [R432-270-11(5)(a-c)] 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. [R432-270-10(5)(a)-(x)] 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.