complaint·May 2, 2025

R1 also confirmed that R1 was not aware of any attempted visit from the day program on 03/24/25. According to R1’s Admission Agreement (page 2, under House Rules/Facility Policies), “visiting hours are open and all residents are encouraged to accept visitors at a time that works best for their individual needs.” Additionally, the facility’s Plan of Operation (page 15, under Personal Rights) states that residents have the right “to have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.” Therefore, the facility did not notify R1 of their visitors on 03 24/5, in violation of both the Admission Agreement and the facility’s Plan of Operation. As a result, this allegation is 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 with Health Services Director Flores and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. Both outside agency representatives confirmed that R1 is actively involved in R1’s care plan and that regular meetings are held with R1 and facility staff. R1 expressed no concerns. A review of R1’s Patient's Rights form dated on 09/10/24 also confirmed this, showing signatures from R1, R1's case manager, placement agency and administrator Caleb. Moreover, on 03/05/25, the facility sent an email to the day program (DP) informing them that R1 would no longer be utilizing their services and that R1 could be discharged from the program. According to a service note from the external agency, R1 verbally expressed that R1 no longer wished to attend day program. This decision was coordinated with Staff 1 (S1) from Social Services at City Creek Assisted Living, and the discontinuation of services was discussed. Additionally, it was discovered that R1 wrote and signed a letter dated 03/14/25, stating, that R1 doesn't want to go to day program. It was alleged that facility staff do not maintain the facility free of odors from incontinence. The investigation included observations, as well as interviews with staff, residents, and two external agency representatives. On 04/01/25, LPA Lee conducted an unannounced visit and toured the facility, including Halls 1, 2, and 3. During the visit, housekeepers were observed cleaning residents’ rooms. LPA Lee inspected 10 resident rooms and did not observe any malodors or incontinence related odors. During today’s visit, 05/01/25, LPA Lee toured the facility with housekeeping supervisor Shante Reyes and no incontinence related odors were observed. Moreover, LPA Lee observed Housekeepers throughout the facility cleaning. LPA Lee interviewed 6 of 9 residents, all of whom reported no concerns regarding facility cleanliness or odors. All 4 interviewed staff members denied the allegation. It was learned that there are two housekeepers assigned in each hall, three halls total during the shift of 7:00 am to 3:30 PM from Monday to Saturday and an additional janitor from 2:00 PM to 6:00 PM, Monday to Friday to clean residents’ rooms and the facility throughout the day. Additionally, two external agency representatives reported having no concerns and confirmed they had not witnessed any odor issues related to incontinence during their visits. Based on information and interview gather there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the investigation revealed the preponderance of evidence standards have not been met. The above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. ________________________________________________________________