Non-compliance follow-up·May 23, 2024

On 2/21/2024 Licensing Program Analyst (LPA) Jaynae Boyles arrived at the facility unannounced to conduct a Case Management Legal visit in accordance with the Stipulation and Order effective 11/03/2023-11/03/2025. A copy of the Stipulation and Order is posted in a conspicuous place and is available for review upon request. LPA met with the Administrator, Cliff Keene. During today's visit, LPA reviewed the following stipulations of the order: 1. Staff shall be sufficient in number, qualifications and competency and shall provide additional back up staff to provide the services necessary to meet residents’ needs · During inspection, LPA observed LIC 500 and staff schedule and found staff to be sufficient in number. LPA observed training that was conducted from November to February which was found to be sufficient. 2. Facility shall inform all current and prospective residents and/or responsible parties of the facility’s probationary license by providing to the residents/residents’ responsible party a copy of the stipulation. · LPA observed notification of the stipulation within the resident file that they or their responsible party was notified of the stipulation. LPA observed notification of the stipulation for new residents in the admissions agreement. 3. Facility shall ensure that each resident is able to receive three nutritionally well-balanced meals which within 30 days of the effective date of the stipulation shall incorporate the policy of maintaining a Daily Resident Meal Check List into the plan of operations. · LPA observed Daily Resident Meal Check list for the last 30 days which is sufficient in ensuring that residents are receiving meals and the staff are checking to ensure that residents are receiving meals if they choose. The Daily Resident Meal Check List is in the plan of operations, as required by the stipulation. 4. Facility shall submit a written summary of hiring and training practices, including job descriptions to the licensing agency. · LPA was provided this documentation by the Administrator on March 29, 2024. LPA observed these documents within the plan of operations at the facility. 5. Facility staff shall submit any unusual incident reports to the licensing agency by the next working day and a written report to be submitted to the licensing agency within seven days following the date of the incident. · LPA has observed that the facility has been reporting incidents timely and submitting the required information to the licensing agency appropriately. LPA observed facility to be in compliance. No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.