City Creek Assisted Living

Based on observation, interview, record review the licensee did not comply with the section cited above. At 1:02 PM, LPA observed a Med-Tech pre-pouring residents’ medications for the afternoon medication pass. During an interview, Med-Tech stated that medications are scheduled to be administered at 2:00 PM. which poses an immediate health, safety or personal rights risk to persons in care.

Based on interviews and records review, the licensee did not comply with the section cited above. A total of nine resident files were reviewed and found to be complete. Of the six staff files reviewed, four were incomplete. Staff 1 (S1) is missing their TB test and First Aid certificate. (S2) is missing their health screening results and 20 hours of continuing education training. (S3) is missing their 20 hours of continuing education training. (S4) is missing their First Aid certificate, which poses/posed a potential health, safety or personal rights risk to persons in care.

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs…This requirement was not met as evidenced by Based on interviews and records review, facility staff admitted that R1’s change in condition was not communicated to R1’s responsible party and documented, this poses a potential risk to residents in care.

Amend Report to Type A and change the reaseon for the citation.87464 (d) Basic ServicesA facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources.This requirement was not met as evidenced by: Based on interview and record reviews when R1 missed 3 dialysis treatment the facility did not seek medical treatment in a timely manner for R1, which posed an immedicate risk to R1 in care.

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.This requirement was not met as evidence by: Based on interviews and records review the facility did not notify R1 of their visitors on March 24, 2025, in violation of both the Admission Agreement and the facility’s Plan of Operation. This posed an immediate risk to residents in care.

“The facility shall be clean … [and] … sanitary … at all times…” This requirement was not met as evidenced by: Based on interviews and observation, facility kitchen areas were not kept in a clean or sanitary condition, which poses an immediate health, safety, and/or personal rights risk.

87468.1(a)(2) Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all the following personal rights:(2) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.This requirement was not met as evidence by: Based on interviews and observation, the facility staff did not respond to residents call lights where two residents call lights was in despair and resident was waiting to be assisted. This posed an immediate health and safety risk to residents in care.

87555 General Food Service Requirements(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared, and served in a safe and healthful manner.This requirement was not met as evidence by: Based on interviews, observations and records review, the facility staff did not provide good quality of food to residents in care. This posed an immediate health and safety risk to residents in care.

87625(b)(3) Managed Incontinence(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry, and that the facility remains free of odors from incontinence.This requirement was not met as evidence by: Based on interviews and observation, the facility staff did not meet incontinence needs of the residents based on interviews and where two residents’ room had a strong and mild urine odor. This posed a potential health and safety risk to residents in care.

87470(b)(3) Infection Control Requirements(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply:(3) There shall be separation and care of residents whose illness requires separation, including quarantine or isolation, from others.This requirement was not met as evidence by: Based on interviews and records review, the facility staff did not properly address scabies in the facility where 4 resident was sent out to ER for scabies and returned to the facility without being isolated by other residents as well as not notifying public health. This posed a potential health and safety risk to residents in care.

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by:Based on interviews and records review facility staff violated residents’ privacy by posting videos of multiple residents on social media. This posed an immediate health and safety risk to residents in care.

87307(d)(2) Personal Accommodations and Services(d) The following space and safety provisions shall apply to all facilities:(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.This requirement was not met as evidence by: Based on records review and observation the facility staff did not ensure that (R1) assistive equipment needs are in good repair. This posed a potential health and safety risk to residents in care.

87468.1(a)(2) Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.This requirement was not met as evidence by: Based on interviews and observation, the facility did not attend to two residents ADLs needs in a timely manner. (R1) waited for 37 minutes before a staff assisted (R1) with toileting needs and (R2) waited 40 minutes to get (R2)’s incontinence brief change. This posed an immediate health and safety risk to residents in care.

87303(i)(1)(B) Maintenance and Operation(i) Facilities shall have signal systems which shall meet the following criteria:(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:(B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met as evidence by:Based on 6 out 9 interviews with residents’ facility staff are not responding to residents ‘call light in a timely manner. Based on observations on 07/29/2024, two residents waited over 30 minutes to received assistance with their ADLs needs.

Based on observation and interview, the administrator did not comply with the section cited above. LPA and administrator Caleb observed resident bedroom # 213 and #110 to have a strong urine odor, which poses/posed a potential health, safety or personal rights risk to persons in care.

87465(a)(4) Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self administered medications as needed.This requirement was not met as evidence by: Based on interviews and records review: the licensee did not ensure that (R1) received (R1)’s medications as prescribed. (R1) MAR log was missing initial for multiple medications for the month of February 2024 and March 2024. It is unknown if medication were administered to (R1). This posed an immediate health and safety risk to R1.

87468.1(a)(2) Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful, and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by:Based on interviews and records review: the licensee/administrator did not ensure that (R1) was assisted with feeding per (R1)’s Individual Service Plan. This posed an immediate health and safety risk to R1.

87465(a)(4) Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.This requirement was not met as evidence by: Based on records review, the administrator did not ensure that (R1)’s medication for Dabigtran Etexilate (blood thinner) was put on hold for 01/08/2024 to 01/10/2024 according to physician’s order since (R1) had a dental extraction on 01/10/2024. This poses an immediate health and safety risk to resident in care.

87211(a)(1)(B) Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below…(D) Any incident which threatens the welfare, safety or health of any resident…This requirement was not met as evidence by: Based on interview and records review, the administrator did not ensure that (R1)’s responsible party received a written report in regards to (R1)’s fall which resulted in (R1) being hospitalized on both 01/26/2024 to 01/29/2024 and 04/13/2024 to 04/17/2024. This poses a potential health and safety risk to resident in care.

87465(6) Incidental Medical and Dental Care The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year...This requirement is not met as evidenced by: Based on observation, interviews and record review, the licensee did not comply with the section cited above. Facility staff did not ensure MARs were being maintained for R1. This posed a potential health and safety risk to residents in care.

87305 Alterations to Existing Building or New Facilities(a) Prior to construction or alterations, all facilities shall obtain a building permit.This requirement has not been met as evidenced by: Based on LPA's observation, records review and interviews the licensee did not comply with the section cited above. The facility did not obtain a building permit prior to alterations to the building by removing a sophet wall and receptionist desk and adding a structured wall and then later removed the structure wall, which poses/posed a potential health, safety or personal rights risk to persons in care.

87615 (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.This was not met as evidenced by: Based on interviews and record reviews, the licensee retained a resident with a stage 3 pressure wound without obtaining an exception from the Department. This posed a potential health and safety risk to the resident in care.

1569.312 Basic services requirement. Every facility...shall provide at least the following basic services: (e) Monitoring...residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.This was not met as evidenced by: Based on interviews and record reviews, the licensee did not ensure to provide adequately, and timely care and monitoring of R4’s pressure wound while in care at the facility, which resulted in the escalation of R4’s pressure wound to stage 3. This poses an immediate health and safety risks to persons in care.

87465(a)(4) The licensee shall assist residents with self-administered medication as needed.This was not met as evidenced by: Based on record reviews and interviews, licensee did not ensure R1’s blood pressure medication was being administered appropriately. This poses a potential health and safety risk to person in care.

87705 Care of Persons with Dementia k) The following initial and continuing requirements must be met... (6) ... facility staff shall ensure the continued safety of residents if they wander away from the facility. This requirement was not met as evidenced by: Based on records review and interviews, the licensee did not ensure staff checked on all residents, resulting in R1 leaving the facility for the entire day and making it to the hospital without staff knowledge. This poses a potential health and safety risk to residents in care.

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed.This requirement was not met as evidenced by: Based on interviews and record reviews, licensee did not ensure that medications were given as ordered consistently for R1 during December 2022. This posed an immediate health and safety risk to residents in care.

1569.312 Basic services requirement. Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This was not met as evidenced by: Based on interviews and record reviews, the facility licensee did not ensure care and supervision (including regularly checking residents) to R1 while in care at the facility which resulted in R1 sustaining multiple injuries consistent with a fall and was left unattended for a extended period of time.

Reporting Requirements (a)Each licensee shall furnish to the licensing agency such reports as the Department may require...(B)Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This was not met as evidenced by: Based on facility and Department record review the Licensee did not ensure a pressure injury/ulcer wound was reported to the Department as required in Title 22 Regulations. This poses an immediate health and safety risk to persons in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities,...(4)To care, supervision, and services that meet their individual needs....This was not met as evidenced by: Based on medical record review, the licensee did not ensure residents in care did not develop ulcer wounds and or pressure injuries. This poses an immediate health and safety risk to persons in care.

87355 Criminal Record Clearance(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement was not met as evidenced by:

87211 Reporting Requirements(a)Each licensee shall furnish to the licensing agency...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days...(B)Any serious injury as determined by the attending physician...This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not ensure residents medical occurence was reported to Community Care Licensing per Title 22 Regulations. This poses a potential health and safety risk to residents in care.

87411 Personnel Requirements (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement was not met as evidenced by: Based on records review, interviews, and observation, the licensee did not ensure staff 2 maintained an active first aid certification which poses an immediate health, safety, or personal rights risk to residents in care.

87465 Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each5/20 facility...(1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews with staff and residents, residents in wheelchairs are not having requested assistance in a timely fashion, which poses an immediate health and safety risk to persons in care.

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4)The licensee shall assist residents with self-administered medications as needed.This requirement was not met as evidenced by: Based on interviews and records review the licensee did not ensure 3 out of 6 residents did not received medications as prescribed, which poses an immediate health and safety risk to persons in care.

87629 Injections (b)...the licensees who admit or retain residents who require injections shall be responsible for the following:(2) Ensuring that sufficient amounts of medicines, test equipment, syringes, needles and other supplies are maintained in the facility.. This requirement was not met as evidenced by: Based on interviews with staff and residents, licensee did not ensure residents were equiped with the appropriate medical equipment, which poses an immediate health and safety risk to residents in care.

87464 Basic services (f) Basic services shall at a minimum include...(6)Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by: Based on interviews and records review the licensee did not provide arrangements for transportation for 1 out of 2 residents to the medical facility of personal choice. This poses a potential health and safey risk to persons in ca

87465(1)(a) Incidental Medical and Dental CareA plan for incidental medical and dental care shall be developed by each facility…(1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews and records review the licensee did not ensure 1 out of 2 residents needs were met which poses an immediate health and safety risk to residents in care.

87629 Injections (b)...the licensees who admit or retain residents who require injections shall be responsible for the following:(1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement was not met as evidenced by: Based on interviews and record review, licensee did not ensure appropriately skilled professionals were administering injections, which poses an immediate health and safety risk to residents in care.

87464 Basic Services (f) Basic services shall...include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code 2(c). This requirement was not met as evidenced by: Based on record review and interview, the licensee did not ensure R1 did not leave the facility unassisted, which poses an immediate health and safety risk to persons in care.

87468.1(a)(2) Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful ...This requirement was not met as evidenced by: Based on observations, the licensee did not ensure an unidentified man and LPA were screened for COVID-19 symptoms and temperature taken prior to being allowed entry into the facility, wich poses an immediate heath and safety risk to residents in care.

87158 Capacity (b)The number of persons that the facility is licensed to admit shall be determined on the basis of the application review by the licensing agency which shall consider:(4) Number of available staff to meet the care needs of the residents. This requirement was not met as evidenced by: Based on interviews, record review, and observations, the licensee did not ensure the facility had adequate number of staff to meet the needs of the residents, which resulted in R1, R2, and R3 not receiving basic services as agreed upon admission. This poses a potential health and safety risk to persons in care.

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed...(2) The licensee shall provide assistance in meeting necessary medical and dental needs...This requirement was not met as evidenced by: Based on record review of three residents, the facility did not ensure to follow the care plan. Resident 1 and Resident 2 had missed medications dosages. Resident 3 had missed medication doses and was not given the APAP machine to use while sleeping. This poses an potential health and safety risk to residents in care.

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by: Based on observations, the licensee did not ensure that all fire extinguishers were inspected annually. The last inspection date was observed to be on 08/11/2020.

87211Reporting Requirements (a) Each licensee...(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...This requirement was not met as evidenced by: Based on interviews, Staff 1 confirmed that the facility did not report missed medications for residents on 09/25/21, which poses a potential health and safety risk to residents in care.

87506 Resident Records b) Each resident’s record shall contain at least the following information: (14) Current centrally stored medications... This requirement was not met as evidenced by: Based on record review, the facility did not have a completed centrally stored log on file for resident 3, which poses a potential health and safety risk to residents in care.

87465 Incidental Medical and Dental Care (5)The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidence by: Based on record and interviews, the licensee did not ensure R1, R2, R3, and R4 were receiving their medication as order by their physician, which poses a potential health and safety risk to residents in care.

87464 Basic Services (f)Basic services shall...include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code 2(c). This requirement was not met as evidenced by: Based on record review and interview, the licensee did not ensure R1 did not leave the facility unassisted, which poses an immediate health and safety risk to persons in care.

87045 (a) Administrator - Qualification and Duties All facilities shall have a qualified and currently certified administrator... When the administrator is not in the facility, there shall be coverage by a designated substitute...This requirement was not met as evidenced by: Based on observations and interviews, the licensee did not inform the resignation of Administrator Kevin and did not send an updated LIC 308, which poses an immediate health and safety risk to residents in care.

87224 Eviction Procedures(c)The licensee shall, in addition to either serving the required thirty (30) days notice , sixty (60) days notice or seeking approval from the Department and service three (3) days notice on the resident... This requirement was not met as evidenced by: Out of the 4 interviews conducted, 2 interviews confirmed R1 was in the process of being evicted from the facility. Based on interviews and record review, the licensee did not ensure 1 out of 2 residents endured proper eviction protocols. This poses a potential health and safety risk to persons in care.