complaint·February 4, 2025

Residents activate the call system by pulling a string in their room, which lights up an indicator outside the room to alert staff that assistance is needed. 4 out of 6 staff members admitted that the facility’s call system is outdated and inefficient, as it relies solely on visual signals rather than sound. This means that if an RA is assisting another resident in their room, the resident who needs help must wait until the RA is available or if another staff member notices the light. Based on records review the facility does not have a system in place to track the call system's performance, other than periodic inspections to ensure it is operational. During the investigation, LPA Lee observed two separate incidents where residents were unable to get timely assistance. On 12/03/24 at 1:46 PM, LPA Lee observed a resident in room 309 needing help, but no RA attended to them until LPA Lee approached Assistant Administrator Katelyn. Upon inspecting the call light, LPA Lee discovered it was not in good working order. A similar issue was observed on 01/29/25, when a resident in room 206 required assistance, but their call light was also found to be malfunctioning. LPA Lee raised these concerns with Administrator Caleb Summerhays and Assistant Administrator Katelyn Flores, specifically addressing the malfunctioning call lights and the lack of response when the lights are not functioning properly. It was alleged that staff were not meeting the incontinence care needs of residents. The investigation included interviews with staff and residents, as well as observations. LPA Lee interviewed 5 out of 8 residents, all of whom expressed concerns about the long wait times for incontinence care from resident aide (RA) staff. Residents mentioned using the call system to request assistance, but RA staff would take 30 minutes to an hour, or sometimes not respond at all, before providing help. During an observation on 01/29/25, LPA Lee noticed a strong urine odor in resident room 106 and a mild urine odor in resident room 213. In an interview with facility staff, it was revealed that the resident in room 106 requires assistance with incontinence care and tends not to use the urinal. LPA Lee recommended that the resident in room 106 may need additional oversight, such as reminders for incontinence care and more frequent cleaning in the room to reduce the strong urine odor. It was alleged that the facility staff did not properly address scabies in the facility. The investigation involved interviews with staff and residents, as well as a review of facility records. LPA Lee interviewed 4 out of 8 residents, who either raised concerns about scabies in the facility or mentioned hearing about other residents having scabies. Continued LIC 9099-C LPA Lee also spoke with facility staff, who stated that it is unclear if there are any cases of scabies since the residents that was sent to the ER for itchiness did not undergo a scratch or skin test and that it may be scabies. Facility staff did confirm that scabies policies and procedures had been implemented. However, it was discovered that while some residents were placed under isolation precautions, they were not actually isolated. Instead, they continued to share rooms with roommates, potentially exposing others to scabies. According to an incident report dated 11/21/24, one resident was sent to the ER for itchiness and later returned to the facility with treatment for scabies. Additionally, incident reports from 01/08/25 and 01/12/25 indicated that three other residents were also sent to the ER for scabies treatment or possible exposure. The investigation revealed that the facility did not follow the physician's orders for timely follow-up after ER visits. For example, Resident 1 (R1) was supposed to follow up with their primary care provider (PCP) within 5 days, but the facility did so 7 days later. Resident 2 (R2) was supposed to follow up within 3 days but was not seen by a PCP until 5 days later. The facility’s City Creek Scabies Policy, dated 12/01/23, specifies in Procedure #3 that physicians' treatment protocols should be followed, but the facility did not follow-up with PCP in a timely manner. Additionally, the policy on page 358 under Treatment Procedure (c.i.) states that "Contact Precautions should be initiated until 24 hours after the first treatment," yet the residents were not placed under isolation precautions and continued to share rooms with roommates. It was also learned that the facility didn’t consult with local health department to report and possible exposure of scabies in the facility. Based on information and interview gather there is a preponderance of evidence to prove the alleged violations occurred, as a result the allegations are SUBSTANTIATED . A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of this LIC 9099, LIC 9099-D page and appeal rights was provided to facility.